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Simulator Training for Endovascular Neurosurgery
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Pipeline Embolization Device for treatment of high cervical and skull base carotid artery dissections: clinical case
Grzegorz Brzezicki1, Dennis J Rivet1, John Reavey-Cantwell1
1Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA.
Insights
The Pipeline Embolization Device (PED) shows promise for treating complex high cervical and skull base dissections, achieving high revascularization rates and pseudoaneurysm obliteration with good short-term outcomes.
Area of Science:
- Vascular Surgery
- Interventional Neurology
- Neuroendovascular Therapy
Background:
- Cervical dissections often treated with anticoagulation, but challenging high cervical and skull base cases may benefit from endovascular intervention.
- The Pipeline Embolization Device (PED) is explored as a treatment for these complex dissections due to distal and tortuous anatomy.
- Retrospective review of 11 patients with 13 carotid dissections treated with PED at a single institution.
Observation:
- Common presentations included cerebrovascular accident/transient ischemic attack (CVA/TIA) and headache/face pain.
- Eleven dissections were associated with pseudoaneurysms; three patients failed medical management.
- Flow-limiting stenosis was the primary indication for endovascular intervention.
Findings:
- Complete revascularization achieved in 91% of vessels; 50% of pseudoaneurysms obliterated immediately post-procedure.
- Follow-up imaging demonstrated patent PEDs without significant in-stent stenosis up to 9 months.
- 75% of pseudoaneurysms were completely obliterated at follow-up, with no new CVA/TIAs reported.
Implications:
- The PED appears to be a safe and viable endovascular treatment option for high cervical and skull base dissections.
- Further long-term studies are necessary to fully ascertain the efficacy of PED in this patient population.
- This technique offers a potential alternative for complex dissections refractory to medical management.
Background:
Most cervical dissections are treated with anticoagulation or antiplatelet agents with very good results; however, some patients may benefit from endovascular intervention. High cervical and skull base dissections are often more challenging to treat because of the distal location and tortuous anatomy. The Pipeline Embolization Device (PED) may be a reasonable treatment option for this indication.
Objectives:
To report a case series of patients treated with the PED for high cervical and skull base dissections, focusing on their presentation, indications for treatment, dissection revascularization success, and pseudoaneurysm obliteration evaluated by imaging, and to review available pertinent literature.
Methods:
We retrospectively reviewed all cases of high cervical and skull base dissections treated with a PED at our institution. Patient clinical characteristics, presentation, procedural and follow-up imaging, and clinical course were analyzed to evaluate for procedure complications, dissection revascularization success, pseudoaneurysm obliteration, and clinical outcome.
Results:
This is a retrospective case series including 11 patients with 13 carotid dissections treated in our center. There were nine traumatic and four spontaneous dissections. The most common presentation was cerebrovascular accident/transient ischemic attack (CVA/TIA; 5 patients) and headache/face pain (4 patients). Eleven dissections were associated with pseudoaneurysms. Three patients failed medical management with anticoagulation, although flow-limiting stenosis was the main indication for endovascular intervention. Up to three PEDs per vessel were deployed. Angioplasty was used in 10 cases. Complete revascularization (<10% residual stenosis) was achieved in 91% of vessels and 50% of pseudoaneurysms were completely or near completely obliterated immediately after PED(s) deployment. Proximal iatrogenic dissection was the only intraoperative complication. Follow-up imaging was available for nine treated vessels and demonstrated patent PEDs without significant in-stent stenosis up to 9 months after intervention. 75% of pseudoaneurysms were completely obliterated at follow-up. One PED partially collapsed but had no neurological consequences. There were no new CVA/TIAs.
Conclusions:
Our initial experience with treatment of high cervical and skull base dissections with the PED appears to show that this technique may be a safe and viable treatment option. However, long-term results are needed to fully evaluate the efficacy of such treatment.
