J Neurol Surg A Cent Eur Neurosurg 2014; 75 - p23
DOI: 10.1055/s-0034-1383759

Endoluminal Reconstruction of Complex Posterior Cerebral Artery Aneurysms with the Pipeline Embolization Device

D. Zumofen 1, 2, E. Raz 1, M. Shapiro 1, T. Becske 1, H. Riina 1, P. K. Nelson 1
  • 1New York University School of Medicine, New York, United States
  • 2Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland

Aims: Historic treatment for posterior cerebral artery (PCA) dissecting aneurysms includes a range of deconstructive methods with or without adjunctive revascularization. These strategies have typically been implemented to address broad circumferential involvement of distal PCA segments. No truly satisfying approach is available to date for lesions arising from the perimesencephalic PCA. We present a series of five consecutive complex proximal PCA aneurysms that underwent successful endoluminal reconstruction with the Pipeline embolization device (PED). We illustrate and discuss how this method may, under appropriate circumstances, efficiently obliterate the aneurysm, preserve perforators and side-branches, reduce mass effect, and prevent recurrence.

Methods: Forty-five patients with aneurysms of the posterior circulation were treated with PED by our team between January 2009 and October 2012. Of these, five patients harbored complex fusiform aneurysms of the proximal PCA.

Results: Aneurysm location included the P1 segment in 1 case, the P2A segment in 3 cases, and the 2PA/P2P transition in one case. Mean aneurysm diameter was 24.8mm (range 5-44mm). Mean neck-width was 8.9mm (range 4-18.8mm). Patients presented with mass effect related symptoms including CNIII palsy in three cases, progressive headache in one case, and dizziness in one case. All but one aneurysm was unruptured at discovery. In the remaining case, the aneurysm underwent reconstruction in the subacute phase following low-grade aneurysmal subarachnoid hemorrhage. Endoluminal reconstruction was performed using one device in four patients, and two PEDs in the remaining case. The presenting symptoms rapidly resolved in three cases, and stabilized in the remaining two patients. Aneurysm obliteration was immediate in one case, within six months in two cases, and within one year in the remaining two patients. Transiently symptomatic subarachnoid effusion from intraprocedural perforator avulsion occurred in one case. No other complications, in particular no case of new permanent neurological deficits and no aneurysm recurrence were recorded over the follow-up time of 220 days (range 170-365 days).

Conclusions: Reconstruction with PED compares favorably to the alternative treatment options in terms of occlusion rate, margin of safety, and neurological outcome. The presented method may hence find consideration as a possible first-line strategy for a carefully selected subset of these challenging cases.