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Vertebral artery stenting in an aneurysm after dissection
Radiography (2000) 6, 51–54 doi:10.1053/radi.1999.0227, available online at http://www.idealibrary.com on
CASE REPORT
Vertebral artery stenting in an aneurysm after dissection B. Griewing, MD, Director*, F. Brassel, MD, Director‡, St. Schlesinger, MD*, V. Schminke, MD* and Ch. Kessler, MD, Director† *Department of Neurology, Rho¨ n-Klinikum AG, Bad Neustadt/Saale, Germany; †Department of Neurology, Ernst-Moritz-Arndt-University, Greifswald, Germany; ‡Department of Neuroradiology, University Hannover, Germany (Received 2 March 1999; revised 26 August 1999; second revision 30 October 1999; accepted 23 November 1999)
Key words: cerebrovascular disease; vertebral artery; stenting; aneurysm; dissection.
Purpose: Traumatic and spontaneous dissections of brain-supplying arteries are the cause of approximately 5% of cerebral infarctions in young adults. They are localized more often in the carotid, and less frequently in vertebral arteries. Aneurysms following dissections, which can develop as a possible embolic source, are generally treated with endovascular surgery. Methods: We describe the case of a 42-year-old man who experienced brain stem and cerebellar infarctions caused by dissections in different segments of both vertebral arteries following an alpine ski run without memorable trauma. Results: Ultrasound and angiographic follow-up examinations showed a complete recanalization of the vessels, but a false aneurysm in the right vertebral artery between cervical vertebrae 3–6 remained. The patient refused surgical intervention. With his informed consent, we performed selective catheter angiography and implanted a stent into the affected arterial segment. During and following the interventional therapy, the patient experienced no clinical complications. Angiographic and ultrasound follow-up revealed no residual aneurysm or stenosis. Conclusions: Stenting of the vertebral artery provides an hopeful nonsurgical alternative for treatment of aneurysms after arterial dissection. © 2000 The College of Radiographers
Introduction Because of the development of non-invasive diagnostic methods, such as magnetic resonance tomography and various ultrasound techniques, the number of published articles on the carotid artery, and to a lesser extent, the vertebral arteries, have increased in the last ten years [1–5]. Following dissection, an aneurysm located in the region of the Correspondence should be addressed to: Dr med. Bernd Griewing, Department of Neurology, Rho¨n-Klinikum AG, von-Guttenberg-Str. 10, 97616 Bad Neustadt, Germany.
1078–8174/00/010051+04 $35.00/0
dissection can develop. They are often treated surgically because of the potential risk of cerebral ischaemia [6]. In the present report we describe the successful stenting of an aneurysm in the V2-segment of a vertebral artery after its dissection, a procedure which was undertaken because the patient refused surgical intervention.
Case history A 42-year-old male with no previous health problems reported experiencing acute double vision as © 2000 The College of Radiographers
52
Grieweing et al.
Figure 1 (a–c) DSA findings: In the acute phase (a) visualization of a dissection of the right extracranial vertebral artery in the V2-segment between cervical vertebrae 3–6; 6 months later complete restitution of the dissection, but an aneurysm remained (b); 9 months after dissection, normal findings after stenting (c).
Stent for vertebral artery aneurysm
well as rotatory vertigo, nausea, vomiting and neck pain following an alpine ski holiday without a fall or other memorable trauma. Four days following the beginning of the symptoms, he visited our clinic. The clinical neurological examination at admission showed Horner’s syndrome on the left side as well as an abduction weakness of the left eye with double vision. Except for a nystagmus when gazing left and a left-sided weakened gag reflex, we found no conspicuous abnormalities of the cranial nerves. With inconspicuous motor findings there existed right hemihypaesthesia and hemihypalgesia. A test of coordination revealed a left hemiataxia. Cranial computer tomography (CCT) and magnetic resonance imaging (MRI) visualized ischaemic infarction in the left and right cerebellar hemispheres. Doppler ultrasound, later confirmed with digital subtraction angiography (DSA), found stenosis in the distal section of the left vertebral artery directly before the transition to the basilar artery. In addition, ultrasound revealed a further dissection of the contralateral vertebral artery between cervical vertebrae 3–6 (V2 segment; Fig. 1(a)). Based on the diagnosis of bilateral dissection of the vertebral artery and excluding other possible causes such as vasculitis, anticoagulation therapy was begun using intravenous heparinization for one week and phenprocoumon p.o. (INR-area; Marcumar) for the following 6 months. The original clinical picture resolved completely. Ultrasonic and, later, angiographic visualization showed complete recanalization of the vertebral arteries following dissection. However, an aneurysm remained in the right vertebral artery, the segment between cervical vertebrae 3–6 (Fig. 1(b)). The patient rejected surgical interventions. With the informed consent of the patient and under the auspices of the Neuroradiology Clinic (F.B.), stenting was performed. Pre-treatment and follow-up were carried out in the Neurology clinic. Heparin (5000 IU) was administered intravenously; and further boluses were given as needed to maintain an activated clotting time during the procedure of 200 to 250 s. Arteriography was performed via femoral arterial puncture, and a standard 5-F cerebral catheter was placed initially into the vertebral artery. DSA was performed to reveal the entire field of the vertebral arteries. The aneurysm was localized in the V2-segment on the level of the 5th cervical vertebra. A wall stent, ‘Magic’ 6.0 medium, was deployed across the lesion. The stent was further dilated at high
53
pressure (14 to 16 atm) to embed it firmly into the vessel wall (Fig. 1(c)). Post-stent anticoagulation was not used. Ticlopidine (2250 mg; Ticlid) was given for 3 weeks and aspirin (300 mg) was continued for 3 months following the intervention. Frequent neurological check-ups were performed by a neurologist during and after the procedure. The patient experienced no complications; all neurological and sonographical followup examinations were normal.
Discussion Vascular stents have recently gained wide popularity. Combined with percutaneous transluminal angioplasty, over the last 3 years there has been a great deal of interest in treating extracranial carotid stenoses, and to a lesser extent vertebral stenoses, with either angioplasty or stents [7–11]. A direct comparison of primary stent placement and surgery in any vascular system, however, has not been completed. The debate continues as to its relative efficacy and applicability compared with surgery, which has been demonstrated convincingly to benefit patients with high-grade symptomatic carotid artery stenoses [12–14]. Aneurysms of the brain supplying arteries are normally treated surgically [6]. To our knowledge, this is one of the first descriptions of successful stenting of an aneurysm, in a vertebral artery, following dissection. This false aneurysm was detected by ultrasound follow-up examinations, not at the original angiography. Despite the limited use of stenting in extracranial vertebral arteries, this selective angiographic procedure was performed because the patient refused surgery. This patient’s clinical situation and his vascular pathology are too rare an occurrence to lead to randomized studies on stent-implantation in such cases in the future. As long as no scientifically firm results derived from comparative trials are available, established surgical techniques are invasive treatments of choice for aneurysms in the vertebral artery or in other locations of the vessels supplying the brain. References 1. Chiras J, Marciano S, Vega-Molina J, Touboul J, Poirier B, Bories J. Spontaneous dissection aneurysms of the extracranial vertebral artery. Neuroradiology 1985; 27: 327–33.
54
2. Dal Pozzo G, Mascalchi M, Fonda C, Cadelo M, Ronchi O, Inzitari D. Lower cranial nerve palsy due to dissection of the internal carotid artery. CT and MR imaging. J Comput Assist Tomog 1989; 13: 989–95. 3. Gould DB, Cunningham K. Internal carotid artery dissection after remote surgery. Iatrogenic complications of anesthesia. Stroke 1995; 25: 1276–8. 4. Hoffmann M, Sacco RL, Chan S, Mohr JP. Noninvasive detection of vertebral artery dissection. Stroke 1994; 23: 815–9. 5. Mokri B, Piegras DG, Houser OW. Traumatic dissections of the extracranial internal carotid artery. J Neurosurg 1988; 68: 189–97. 6. Sundt T, Pearson BW, Piegpras DG, Houser OW, Mokri B. Surgical management of aneurysms of the distal extracranial internal carotid artery. J Neurosurg 1986; 64: 169–70. 7. Yadav JS, Roubin GS, King P, Iyer S, Vitek J. Angioplasty and stenting for restenosis after carotid endarterectomy. Stroke 1996; 27: 2075–9. 8. Kachel R. Percutaneous transluminal angioplasty (PTA) of supra-aortic arteries especially of the carotid and
Grieweing et al.
9. 10. 11. 12.
13.
14.
vertebral artery. An alternative to vascular surgery? J Mal Vasc (Paris) 1993; 18: 254–7. Gotta J. Elective stenting of extracranial carotid arteries. Circulation 1997; 95: 303–5. Crawley F, Brown MM, Clifton AG. Angioplasty and stenting in the carotid and vertebral arteries. Postgrad Med J 1998; 74: 7–10. Naylor AR, London NJ, Bell PR. Carotid and vertebral artery transluminal angioplasty study. Lancet 1997; 349: 1324–5. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445–53. European Carotid Surgery Trialists Group: MRC European Carotid Surgery Trial. Interim results for symptomatic patients with severe (70–90%) or with mild (0–29%) carotid stenosis. Lancet 1991; 337: 1235–43. Asymptomatic Carotid Atherosclerosis Study. Clinical advisory: Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. Stroke 1994; 25: 2523–4.
CASE REPORT
Vertebral artery stenting in an aneurysm after dissection B. Griewing, MD, Director*, F. Brassel, MD, Director‡, St. Schlesinger, MD*, V. Schminke, MD* and Ch. Kessler, MD, Director† *Department of Neurology, Rho¨ n-Klinikum AG, Bad Neustadt/Saale, Germany; †Department of Neurology, Ernst-Moritz-Arndt-University, Greifswald, Germany; ‡Department of Neuroradiology, University Hannover, Germany (Received 2 March 1999; revised 26 August 1999; second revision 30 October 1999; accepted 23 November 1999)
Key words: cerebrovascular disease; vertebral artery; stenting; aneurysm; dissection.
Purpose: Traumatic and spontaneous dissections of brain-supplying arteries are the cause of approximately 5% of cerebral infarctions in young adults. They are localized more often in the carotid, and less frequently in vertebral arteries. Aneurysms following dissections, which can develop as a possible embolic source, are generally treated with endovascular surgery. Methods: We describe the case of a 42-year-old man who experienced brain stem and cerebellar infarctions caused by dissections in different segments of both vertebral arteries following an alpine ski run without memorable trauma. Results: Ultrasound and angiographic follow-up examinations showed a complete recanalization of the vessels, but a false aneurysm in the right vertebral artery between cervical vertebrae 3–6 remained. The patient refused surgical intervention. With his informed consent, we performed selective catheter angiography and implanted a stent into the affected arterial segment. During and following the interventional therapy, the patient experienced no clinical complications. Angiographic and ultrasound follow-up revealed no residual aneurysm or stenosis. Conclusions: Stenting of the vertebral artery provides an hopeful nonsurgical alternative for treatment of aneurysms after arterial dissection. © 2000 The College of Radiographers
Introduction Because of the development of non-invasive diagnostic methods, such as magnetic resonance tomography and various ultrasound techniques, the number of published articles on the carotid artery, and to a lesser extent, the vertebral arteries, have increased in the last ten years [1–5]. Following dissection, an aneurysm located in the region of the Correspondence should be addressed to: Dr med. Bernd Griewing, Department of Neurology, Rho¨n-Klinikum AG, von-Guttenberg-Str. 10, 97616 Bad Neustadt, Germany.
1078–8174/00/010051+04 $35.00/0
dissection can develop. They are often treated surgically because of the potential risk of cerebral ischaemia [6]. In the present report we describe the successful stenting of an aneurysm in the V2-segment of a vertebral artery after its dissection, a procedure which was undertaken because the patient refused surgical intervention.
Case history A 42-year-old male with no previous health problems reported experiencing acute double vision as © 2000 The College of Radiographers
52
Grieweing et al.
Figure 1 (a–c) DSA findings: In the acute phase (a) visualization of a dissection of the right extracranial vertebral artery in the V2-segment between cervical vertebrae 3–6; 6 months later complete restitution of the dissection, but an aneurysm remained (b); 9 months after dissection, normal findings after stenting (c).
Stent for vertebral artery aneurysm
well as rotatory vertigo, nausea, vomiting and neck pain following an alpine ski holiday without a fall or other memorable trauma. Four days following the beginning of the symptoms, he visited our clinic. The clinical neurological examination at admission showed Horner’s syndrome on the left side as well as an abduction weakness of the left eye with double vision. Except for a nystagmus when gazing left and a left-sided weakened gag reflex, we found no conspicuous abnormalities of the cranial nerves. With inconspicuous motor findings there existed right hemihypaesthesia and hemihypalgesia. A test of coordination revealed a left hemiataxia. Cranial computer tomography (CCT) and magnetic resonance imaging (MRI) visualized ischaemic infarction in the left and right cerebellar hemispheres. Doppler ultrasound, later confirmed with digital subtraction angiography (DSA), found stenosis in the distal section of the left vertebral artery directly before the transition to the basilar artery. In addition, ultrasound revealed a further dissection of the contralateral vertebral artery between cervical vertebrae 3–6 (V2 segment; Fig. 1(a)). Based on the diagnosis of bilateral dissection of the vertebral artery and excluding other possible causes such as vasculitis, anticoagulation therapy was begun using intravenous heparinization for one week and phenprocoumon p.o. (INR-area; Marcumar) for the following 6 months. The original clinical picture resolved completely. Ultrasonic and, later, angiographic visualization showed complete recanalization of the vertebral arteries following dissection. However, an aneurysm remained in the right vertebral artery, the segment between cervical vertebrae 3–6 (Fig. 1(b)). The patient rejected surgical interventions. With the informed consent of the patient and under the auspices of the Neuroradiology Clinic (F.B.), stenting was performed. Pre-treatment and follow-up were carried out in the Neurology clinic. Heparin (5000 IU) was administered intravenously; and further boluses were given as needed to maintain an activated clotting time during the procedure of 200 to 250 s. Arteriography was performed via femoral arterial puncture, and a standard 5-F cerebral catheter was placed initially into the vertebral artery. DSA was performed to reveal the entire field of the vertebral arteries. The aneurysm was localized in the V2-segment on the level of the 5th cervical vertebra. A wall stent, ‘Magic’ 6.0 medium, was deployed across the lesion. The stent was further dilated at high
53
pressure (14 to 16 atm) to embed it firmly into the vessel wall (Fig. 1(c)). Post-stent anticoagulation was not used. Ticlopidine (2250 mg; Ticlid) was given for 3 weeks and aspirin (300 mg) was continued for 3 months following the intervention. Frequent neurological check-ups were performed by a neurologist during and after the procedure. The patient experienced no complications; all neurological and sonographical followup examinations were normal.
Discussion Vascular stents have recently gained wide popularity. Combined with percutaneous transluminal angioplasty, over the last 3 years there has been a great deal of interest in treating extracranial carotid stenoses, and to a lesser extent vertebral stenoses, with either angioplasty or stents [7–11]. A direct comparison of primary stent placement and surgery in any vascular system, however, has not been completed. The debate continues as to its relative efficacy and applicability compared with surgery, which has been demonstrated convincingly to benefit patients with high-grade symptomatic carotid artery stenoses [12–14]. Aneurysms of the brain supplying arteries are normally treated surgically [6]. To our knowledge, this is one of the first descriptions of successful stenting of an aneurysm, in a vertebral artery, following dissection. This false aneurysm was detected by ultrasound follow-up examinations, not at the original angiography. Despite the limited use of stenting in extracranial vertebral arteries, this selective angiographic procedure was performed because the patient refused surgery. This patient’s clinical situation and his vascular pathology are too rare an occurrence to lead to randomized studies on stent-implantation in such cases in the future. As long as no scientifically firm results derived from comparative trials are available, established surgical techniques are invasive treatments of choice for aneurysms in the vertebral artery or in other locations of the vessels supplying the brain. References 1. Chiras J, Marciano S, Vega-Molina J, Touboul J, Poirier B, Bories J. Spontaneous dissection aneurysms of the extracranial vertebral artery. Neuroradiology 1985; 27: 327–33.
54
2. Dal Pozzo G, Mascalchi M, Fonda C, Cadelo M, Ronchi O, Inzitari D. Lower cranial nerve palsy due to dissection of the internal carotid artery. CT and MR imaging. J Comput Assist Tomog 1989; 13: 989–95. 3. Gould DB, Cunningham K. Internal carotid artery dissection after remote surgery. Iatrogenic complications of anesthesia. Stroke 1995; 25: 1276–8. 4. Hoffmann M, Sacco RL, Chan S, Mohr JP. Noninvasive detection of vertebral artery dissection. Stroke 1994; 23: 815–9. 5. Mokri B, Piegras DG, Houser OW. Traumatic dissections of the extracranial internal carotid artery. J Neurosurg 1988; 68: 189–97. 6. Sundt T, Pearson BW, Piegpras DG, Houser OW, Mokri B. Surgical management of aneurysms of the distal extracranial internal carotid artery. J Neurosurg 1986; 64: 169–70. 7. Yadav JS, Roubin GS, King P, Iyer S, Vitek J. Angioplasty and stenting for restenosis after carotid endarterectomy. Stroke 1996; 27: 2075–9. 8. Kachel R. Percutaneous transluminal angioplasty (PTA) of supra-aortic arteries especially of the carotid and
Grieweing et al.
9. 10. 11. 12.
13.
14.
vertebral artery. An alternative to vascular surgery? J Mal Vasc (Paris) 1993; 18: 254–7. Gotta J. Elective stenting of extracranial carotid arteries. Circulation 1997; 95: 303–5. Crawley F, Brown MM, Clifton AG. Angioplasty and stenting in the carotid and vertebral arteries. Postgrad Med J 1998; 74: 7–10. Naylor AR, London NJ, Bell PR. Carotid and vertebral artery transluminal angioplasty study. Lancet 1997; 349: 1324–5. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445–53. European Carotid Surgery Trialists Group: MRC European Carotid Surgery Trial. Interim results for symptomatic patients with severe (70–90%) or with mild (0–29%) carotid stenosis. Lancet 1991; 337: 1235–43. Asymptomatic Carotid Atherosclerosis Study. Clinical advisory: Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. Stroke 1994; 25: 2523–4.