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Fusiform/Dissecting Aneurysms

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Eight Aneurysms

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Abstract

Fusiform and dissecting aneurysms have different pathological processes but often share the same appearance on angiogram images. The major pathological features are introduced. The current classification of fusiform/dissecting aneurysms is confusing. Considering the natural pathological process and purpose of treatment, a new classification of combined fusiform/dissecting aneurysms is suggested and introduced in detail to guide the selection of treatment strategy. The natural history of the fusiform/dissecting aneurysm is discussed by reviewing the currently available literature. The treatment strategies and techniques for different fusiform/dissecting aneurysms are discussed. The flow diverter treatment, the most commonly used treatment modality, is discussed in detail.

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Authors and Affiliations

  1. Department of Neurosurgery, Affiliated Hospital of Guiyang Medical University, Guiyang, Guizhou, China

    Zeguang Ren

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  1. Zeguang Ren
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Case Presentation

Case Presentation

Case 12.1 Ruptured Bilateral VA Dissecting Aneurysm (Type IIc) Treated with PEDs

Case Pearls

  1. 1.

    Dissecting aneurysm is commonly seen at posterior circulation.

  2. 2.

    FD stent is the preferred treatment for VA/BA dissecting aneurysm.

  3. 3.

    Vasospasm from SAH can cause the migration/foreshortening of FD device.

  4. 4.

    Anticoagulation treatment may lead to dissecting aneurysm rupture.

figure jfigure jfigure j

(a): Normal screen MRI 20 months prior to presentation with history of genetic kidney disease and presenting head CT showing SAH 7 days after transplant surgery; (b, c): pre-embo 3D and 2D views showing right VA V4 segment fusiform or dissecting aneurysm. FD stent treatment was planned; (d): immediate angiogram after FD stent (PED3.5x20x2) placement; (e and f): un-subtracted and single-shot X-ray showing PED contour and wall apposition; (g): left VA angiogram, distal left VA is slightly ectatic; (h): 6-day follow-up, stable, right VA dissecting aneurysm still has residual filling, left VA possible fusiform vs ectatic dilation slightly larger; (i): 10 days angio for increased TCD showing near occlusion of distal left VA (vasospasm vs progression dissection?), clinically stable. (j): routine follow-up CT after VP shunt on day 9 showing no IVH; (k): new IVH on follow-up head CT on day 12 (1 day after heparin drip for DVT); (l): angiograms showing diffuse vasospasm, unchanged previously treated right vertebral artery dissecting aneurysm with pipeline stent foreshortening slightly. Left V4 segment of vertebral artery fusiform dilation was grossly unchanged. The very distal left V4 is near occluded. At this point, an unclear source of the new hemorrhage, possible left VA dissecting aneurysm rupture, was suspected; additional PED for right VA aneurysm and endovascular treatment of left VA were considered. Relatively large left AICA was arising from the left dissecting aneurysm; coil occlusion of the distal left VA is a less ideal option of treatment. FD stent was chosen for the treatment of left VA dissecting aneurysm; (m): balloon angioplasty of proximal BA; (n and o): additional PED (3.5 x20) was placed in the distal end of right VA dissecting aneurysm for covering the foreshorten PED. Un-subtracted angiogram (n) and single shot (o) for PED contour and wall apposition; (p): control angiogram after angioplasty, right PED placement. (q and r): PED (3.5x20) placement for left VA, PED already in BA limited the leading wire of new PED device being put more distally. (s and t): angiogram after left VA PED placement, single-shot X-ray showing the contour of left VA PED. (u–z): 6-month follow-up angiogram; control angiogram (u, w, and y) and single shot for PED contours (v, x, and z)

Case 12.2 FD Plus Additional Coiling for a Large Dolichoectatic Fusiform (Type IIIa) Aneurysm of Vertebrobasilar Junction

Case Pearls

  1. 1.

    Flow diverter is the standard treatment for posterior circulation fusiform/dissecting aneurysms.

  2. 2.

    Additional coil placement helps with stabilizing the FD stent and facilitates thrombosis of the aneurysm.

  3. 3.

    Contralateral VA needs to be occluded distally to prevent direct filling of the aneurysm.

figure m

(a): 3D angiogram showing large dolichoectatic fusiform aneurysm of vertebrobasilar junction (type IIIa) with known “fusiform” aneurysm and new presentation of cranial nerve palsy; (b, c): pre-embo 2D views; (d–f): FD stent placement (PED 5x35 x2, 5x30, 5x25); (g): coil placement inside the aneurysm through microcatheter in right VA; (h): coil occlusion (arrow) of distal end of left VA, insert showing the final coil and PED contour; (i): 8-month follow-up showing complete occlusion of the fusiform aneurysm, suboptimal angiogram with subclavian injection

Case 12.3 Type IIa vs IIb Ruptured VA Fusiform/Dissecting Aneurysm Treated with FD Device

Case Pearls

  1. 1.

    Angiographic features help to differentiate the fusiform from dissecting aneurysm. Vessel wall imaging study is needed to definitively differentiate fusiform from dissecting aneurysm.

  2. 2.

    The treatment strategy is identical between the true fusiform and dissecting aneurysm most of the time.

  3. 3.

    Dissecting aneurysm potentially has more insidious clinical/pathological process than fusiform aneurysm.

figure n

(a): Presenting head CT showing SAH; (b): pre-embo 3D, right V4 fusiform aneurysm without stenosis (type IIa, no vessel wall imaging to confirm dissection); (c and d): pre-embo 2D AP and lateral views; (e–h): angiograms after placement of FD device (PED 4.5x35). (i and j): 6-month follow-up angiogram with restored normal lumen of right V4 segment; (k): 16-month follow-up MRA

Case 12.4 Vertebral Artery V4 Dissecting Aneurysm (Type IIc) Treated with FD Device

Case Pearls

  1. 1.

    FD is the preferred option for ruptured VA dissecting aneurysm given the surgical option is limited.

  2. 2.

    DAPT is needed for FD and management of DAPT tailored to potential surgical intervention.

  3. 3.

    Normally, balloon angioplasty is not needed as FD device is self-expanded completely most of the time for stenotic dissecting (type IIc or IIIc) aneurysms.

figure o

(a): Presenting head CT showing SAH; (b): pre-embo 3D, left V4 dissecting aneurysm with stenosis (type IIc); (c and d): pre-embo 2D AP and lateral views; (e–h): angiogram after placement of FD device (PED 3.5 x18 and 3.5 x14); no angioplasty was needed; (i and j): 8-month follow-up angiograms with restored normal lumen of left V4 segment

Case 12.5 Cervical Carotid Dissecting Aneurysm (Type IIc) Treated with FD Device

Case Pearls

  1. 1.

    Cervical dissecting aneurysms often arise from mild trauma or connective tissue disease associated.

  2. 2.

    Covered stent vs FD vs regular carotid stent can be chosen based on straight or tortuous segment involvement or if there is accompanying pseudoaneurysm.

figure p

(a): MRI (A) and CTA for work-up of facial pressure and tinnitus in the right ear showed dissecting cervical ICA with stenosis (type IIc, circle area); (b, c): pre-embo 2D AP and lateral views of cervical run showing stenotic mid cervical ICA; (d, e): FD device (PED, 4.5x35) placement and no angioplasty was needed; (f, g): 3-month follow-up angiogram restored cervical ICA lumen, inserts for PED contour

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Ren, Z. (2022). Fusiform/Dissecting Aneurysms. In: Eight Aneurysms. Springer, Cham. https://doi.org/10.1007/978-3-030-97216-5_12

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  • DOI: https://doi.org/10.1007/978-3-030-97216-5_12

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-97215-8

  • Online ISBN: 978-3-030-97216-5

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