Efficacy, complications and clinical outcome of endovascular treatment for intracranial intradural arterial dissections

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Abstract

Objective

Intracranial intradural dissections are challenging to treat, and published data regarding treatment outcomes remains relatively limited. We retrospectively evaluated our experience with endovascular techniques in the treatment of intracranial intradural dissections, and describe the efficacy and clinical outcomes with treatment.

Methods

Between January 2003 and December 2011, 23 patients with 23 intracranial intradural arterial dissections underwent endovascular treatment at our institution. Eighteen were treated with coil embolization (14 with parent vessel sacrifice, 4 with aneurysm coiling), 4 with flow diverting stents (Pipeline Embolization Device) and 1 with primary angioplasty and stenting. Treatment indications were subarachnoid hemorrhage (n = 16), cerebral ischemia (n = 2), headache (n = 3), or elective (n = 2).

Results

The peri-procedural complication rate was 17.4%, 3 of the 4 cases sustained no serious clinical sequelae. Four deaths unrelated to the procedure occurred in patients with subarachnoid hemorrhage. Angiographic follow-up demonstrated complete occlusion in 8 of 14 surviving cases treated by coil embolization, incomplete occlusion in 2 cases. Four cases were lost to follow-up, but all of these had complete occlusion post-procedure. Successful angiographic outcomes were seen at follow-up in patients treated with flow diverting stents and primary intracranial stenting. Clinical follow-up showed a mRS of 0–1 in 15 (78.9%) of 19 patients, mRS of 2 in 1 patient, mRS of 3 in 1 patient and mRS of 5 in 1 patient. There was no neurological deterioration, re-bleeding or deaths during the follow-up period.

Conclusion

Intracranial arterial dissections, particularly those presenting with subarachnoid hemorrhage, are lesions associated with high mortality. They can be effectively managed endovascularly. In our experience, endovascular treatment can be associated with moderate peri-procedural risks.

Introduction

Intracranial arterial dissection is a recognized cause of ischemic stroke and subarachnoid hemorrhage [1], [2]. Dissection between the intima and media leads to luminal narrowing or occlusion. Conversely, dissections involving the media and adventitia interface have the potential to rupture into the subarachnoid space [3], [4]. Patients tend to present with either ischemic complications or subarachnoid hemorrhage, but rarely both, and treatment options depend largely on the clinical presentation.

In the setting of cerebral ischemia, anticoagulation and antiplatelet therapy have been advocated and have demonstrated efficacy in small case series [3], [5]. Surgical or endovascular intervention is reserved for patients with recurrent ischemic symptoms despite medical therapy, or where medical therapy is contraindicated. In patients presenting with subarachnoid hemorrhage, the rebleeding rate is considerable, ranging between 30% and 70%, and rebleeding usually occurs within 24 h of the initial rupture [6], [7]. In this group of patients, consideration of early treatment by surgery or endovascular procedures is strongly indicated [8], [9].

Approaches to endovascular treatment of intracranial dissections has evolved over time, and currently includes a variety of occlusive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow through the parent artery) techniques, including coil embolization, stent placement, stent or balloon assisted coiling and use of flow diverting stents. A combination of techniques are used, depending on anatomical factors of the dissection, as well as the clinical presentation. For example, endovascular treatment of dissections presenting with ischemia, typically involves angioplasty or stenting.

Current published literature on endovascular treatment of intracranial dissection remains relatively limited. In this study, we sought to describe the efficacy, safety, and clinical outcomes in our experience with endovascular treatment of intracranial intradural dissections.

Section snippets

Methods

Between January 2003 and December 2011, 23 patients with 23 intracranial intradural dissections underwent endovascular treatment at our institution. These patients were identified from a prospectively recorded database which contained all cases of endovascular treatment performed in this time period. Only dissections which involved intradural arterial segments were included. All patients were evaluated by a multidisciplinary team including neurointerventionists, neurosurgeons and neurologists,

Results

The age of our patients ranged from 13.1 to 70.6 years, with a mean of 46.6 years and a slight female predominance (male: female ratio, 10:13). A clear history of hypertension was present in 10 (43.5%) of 23 patients, and five (21.7%) patients had fibromuscular dysplasia. A traumatic event at, or preceding presentation was identified in 6 (26.1%) patients (Table 1).

Locations of the dissections are described in Table 2. The large majority of dissections, 22 (95.6%) of 23 dissections, were

Discussion

Intradural arterial dissection is uncommon, and comparably few studies examine the efficacy and clinical follow-up outcomes following endovascular treatment [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. Our study presents a relatively large series of endovascularly treated intradural dissections. Our data indicates that endovascular treatment is associated with moderate peri-procedural morbidity, 17.4%. However, considering the diversity of initial patient clinical symptoms

Conclusion

Patients presenting with intracranial dissection and subarachnoid hemorrhage who do not receive intervention are recognized as having poor clinical outcomes. Our experience with endovascular treatment over a 9-year period demonstrates moderate peri-procedural morbidity and mortality rates with endovascular treatment. We achieved good angiographic and midterm clinical outcomes. Preliminary experience suggests that flow-diverting devices offer a valuable alternative strategy when vessel sacrifice

Financial disclosures

None.

Conflict of interest

None.

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