Endovascular Coil Embolization of Dissecting distal MCA Aneurysm with ICH in Paediatrics age group

1. Dr. Shahnawaz Alam
MCh-Neurosurgery
Moderated by:
Dr. V. C. Jha
HOD, Dept. of Neurosurgery
Endovascular Coil Embolization of Dissecting
distal MCA Aneurysm with ICH in Paediatrics
age group

2. • Spontaneous intracranial arterial dissection (IAD) has become increasingly
important as a cause of stroke, such as subarachnoid hemorrhage (SAH)
and hemodynamic or thromboembolic cerebral ischemia, with the
development of diagnostic imaging methods.
• Spontaneous IAD mainly occurs in the posterior circulation, and is
relatively rare in the anterior circulation including the middle cerebral
artery (MCA).
• MCA aneurysm rupture and re-rupture has got a high mortality rate of
more than 60% within 2 years.*
 Choi IS, David C. Giant intracranial aneurysms: development, clinical presentation and treatment. Eur J Radiol. 2003;46:178–194.
 Drake CG, Peerless SJ. Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992. J
Neurosurg.1997;87:141–162.
INTRODUCTION

3. Brief History & examination:
 12 yrs/F, Right handedness, H/o supplemented by her father
 C/o: Sudden severe headache with LOC followed by fall in the bathroom
3 days ago.
 H/o: nausea and vomiting, Neck tightness
 No H/O any source of infection
 O/E: Vitals: PR-108/mint., BP-112/74,RR-28, Spo2 96% on RA,GCS- E1V1M4
 Rt. Pupil mid-dilated, sluggish reactive; Lt. RL, 2mm
 Power:Rt.5/5, Lt.1/5, DTR 2+, Tone & Bulk- Normal
 Intubated and put on ventilatory support; Plan: DSA on Emergency basis
CASE DESCRIPTION

4. 18 Nov

5. Diagnostic DSA: Selective 6 Vessels; 20 Nov
Dissecting MCA ANEURYSM at Rt.M2-M3 JUNCTION

6. DSA 3D Rec

7. Interventional Workspot
Serial Coil Embolization

8. Serial Check SCAN

9. POD 15

10. POD-15

11.  Tsukahara T, Minematsu K. Overview of spontaneous cervicocephalic arterial dissection in Japan. Acta Neurochir Suppl. 2010;107:35–40.
 Lee JS, Bang OY, Lee PH, et al. Two case of spontaneous middle cerebral arterial dissection causing ischemic stroke. J Neurol Sci.
2006;205:162-166.
DISCUSSION & LITERATURE REVIEW
• Various surgical and endovascular treatment methods have been proposed, but
no consensus has been reached on achieving secure hemostasis and
preservation of adequate blood flow to the perforating artery from the
dissecting lesion as well as the distal area.
• Case reports of IAD in the MCA treated with trapping of the dissecting lesion
and bypass using STA-MCA, radial artery graft (RAG) to the MCA which
preserved an important perforating artery, the lenticulostriate artery (LSA)
have been reported.

12. • ICH in a non-hypertensive young patient is commonly caused by trauma, drug
abuse, coagulation disorders and cerebral AVM.
• Cases of dissecting MCA aneurysm causing intracerebral hemorrhage years after
the non-hemorrhagic onset have been reported.*
• Most dissections of the carotid and vertebral arteries heal spontaneously and, in
particular, extracranial carotid and vertebral artery dissections generally carry a
favorable prognosis.
• However, as intracranial dissections are usually associated with severe
neurological deficits or SAH and thus carry a poor prognosis because of the
high rate of early re-bleeding, urgent surgical intervention may be required in
patients presenting with hemorrhage.
 Isono M, Abe T, Goda M, Ishii K, Kobayashi H. Middle cerebral artery dissecting aneurysm causing intracerebral hemorrhage 4 years
after the non-hemorrhagic onset: a case report. Surg Neurol. 2002;57(5):346-350.
 Joshua SA, Nayak SG, Pare VS, Ashok, Sebastian R. Unruptured Intracranial Aneurysm Involving the Distal Anterior Cerebral Artery: A
Cadaveric Study. Journal of Case Reports. 2013;3(1):5-9.

13. • MCADAs were diagnosed when DSA revealed fusiform or irregular dilations
of M1, of M2 segment of the MCA, or at the MCA bifurcation with or without
stenosis in the affected segment.
• These dilations typically showed a string sign, a string-and-pearl sign, a pearl
sign, a rosette sign, contrast medium retention, pseudoaneurysm, arterial
occlusion, or a double lumen sign. *
 Maillo A, Díaz P, Morales F. Dissecting aneurysm of the posterior cerebral artery: spontaneous resolution. Neurosurgery. 1991; 29:291–294.
 Mizutani T, Kojima H, Asamoto S, Miki Y. Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms. J Neurosurg. 2001; 9
4:712–717.
 Isono M, Abe T, Goda M, Ishii K, Kobayashi H. Middle cerebral artery dissecting aneurysm causing intracerebral hemorrhage 4 years after the non-hemorr
hagic onset: a case report. Surg Neurol. 2002; 57:346–349. discussion 349-350

14. • MCA dissection manifests predominantly with cerebral ischemia, whereas
aneurysmal dilated dissection (dissecting aneurysm), which manifests with
SAH is relatively rare.
• It is still unclear whether treatment options for these conditions should be the
same options used for treatment of vertebral artery dissecting aneurysms.
• Trapping or coil embolization for vertebral artery dissecting aneurysms has
been historically preferred when contralateral blood flow is deemed to be
sufficient.
• However, for MCADAs, a deconstructive approach without an efficient
bypass is difficult to achieve and poses a great risk of severe hemiparesis or
hemiplegia as a result of striato-capsular infarction. *
 Kondoh R, Utsugisawa K, Obara D, Mizuno M, Yonezawa H, Terayama Y. Striatocapsular infarc- tion caused by middle cerebral artery
dissection. Eur Neurol. 2004;51:120-121.
 Torihashi K, Chin M, Sadamasa N, Yoshida K, Narumi O, Yamagata S. Ischemic stroke due to dissection of the middle cerebral artery treated
by superficial temporal artery-middle cerebral artery anastomosis—case report. Neurol Med Chir (Tokyo). 2011;51:503-506.
 Jung JM, Lee YH, Park MH, Kwon DY. Shadow sign in a T2* brain image in spontaneous middle cerebral artery dissection. Neurology.
2013;80:419.
 Chuang MJ, Lu CH, Cheng MH. Management of middle cerebral artery dissecting aneurysm. Asian J Surg. 2012;35:42-48.
 KurataA,OhmomoT,MiyasakaY,FujiiK,KanS, Kitahara T. Coil embolization for the treatment of ruptured dissecting vertebral aneurysms. AJNR
Am J Neuroradiol. 2001;22:11-18.

15. • Treatment strategy for IAD of the MCA should be planned for each patient and
condition, and surgery should be performed promptly to prevent critical
rebleeding after SAH considering the high recurrence rate.
• In addition, preventing re-rupture of the IAD and preserving important
perforators around the lesion and blood flow distal to the dissection should
be targets of the treatment strategy.
• Clipping is first-line therapy for saccular MCA aneurysms; however, the procedure
is extremely difficult and carries substantial risk.
• Endovascular treatment is an alternative choice for the treatment of MCADAs,
which can be classified into conventional coiling, stent-assisted coiling, and
occlusion of the parent artery.
• Several investigators recently reported successful application of the flow diverter
in ruptured MCADAs with a reasonably low complication rate.

16. 14 MCADAs were identified; 2 patients harbored multiple aneurysms,
and 1 had an additional duralAVF. To treat MCADAs, 19 stents, 64 coils,
and 0.5-mL Onyx were used. Stent-assisted coiling was used in 12
patients, coil alone was used in 1 patient, and parent vessel occlusion
was used in 1 patient; coiling with a single stent was performed in 6
patients, and coiling with double overlapping stents was performed in 6
patients. All dissecting and other aneurysms were successfully treated at the first

17. •. 2017 Dec;45(12):1093-1099.
doi: 10.11477/mf.1436203653.
[Ruptured Dissecting Aneurysm of M2 Portion of the Middle Cerebral Artery:A Case Report]
[Article in Japanese]
Yutaka Fukushima1, Tomohiro Takaki, Shinichiro Yoshino, Katsuyuki Hirakawa, Tooru Inoue
Affiliations
•PMID: 29262391
•DOI: 10.11477/mf.1436203653
• A 71-year-old woman presented with a sudden onset of headache and vomiting. CT showed diffuse SAH
that was more severe on the right side. 3D-CT angiography demonstrated 2 mm microaneurysms at the
middle cerebral artery(MCA)bifurcation and anterior communicating artery, with slight narrowing and
dilatation of the M2 inferior trunk. Each microaneurysm was smooth, making it difficult to identify the
bleeding source.
• Thus, surgery was postponed at the acute stage, and further investigation was planned. Repeated CAG
was diagnostically unsuccessful, finding no source of the bleeding. On day 45 after the onset,
exploratory craniotomy was performed to confirm the cause of the SAH.
• During the operation, both microaneurysms were found to be unruptured. However, the distal portion of
the M2 inferior trunk was dark purplish and red and enlarged in a fusiform shape, suggesting a
dissecting aneurysm. Residue of the SAH observed near the enlarged vessel identified it as the bleeding
source. The enlarged vessel was wrapped with Bemsheets, and the Bemsheets was clipped to secure it.
• A dissecting aneurysm of the distal MCA is rare, as is the onset of bleeding. Based on
a review of the literature related to dissecting aneurysms of the distal MCA, we
recommend exploratory craniotomy if CT demonstrates laterality of the sylvian
fissure on the SAH and CAG reveals stenosis or occlusion of the distal MCA in cases
of SAH for which no bleeding source is detected

18. •. 2010 Sep;152(9):1511-7.
doi: 10.1007/s00701-010-0688-4. Epub 2010 May 20.
Ruptured dissecting cerebral aneurysms in young people: report of three cases
Stefano Peron1, Luis Jimenez-Roldán, Marta Cicuendez, Jose María Millán, Jose Ramón Ricoy, Ramiro D Lobato, Rafael Alday, José F Alén, Alfonso Lagares
Affiliations
•PMID: 20490577
•DOI: 10.1007/s00701-010-0688-4
• Intracranial arterial aneurysms in the pediatric population are rare. Among these, dissecting aneurysms
are the most frequent, followed by saccular, infectious, and posttraumatic. It is widely known that
aneurysmal rupture is uncommon in the first two decades of life. Spontaneous dissecting aneurysms (SDAs) of
the middle cerebral artery (MCA) affecting young individuals most frequently present as occlusive syndrome
with ischemia, although bleeding and subarachnoid hemorrhage can also occur.
• Between March 2006 and January 2008, three young patients (20 months, 8 and 20 years old) were surgically
treated for MCA SDA in the Neurosurgical Department of "12 de Octubre" Hospital of Madrid. These patients
showed hemorrhage as primary radiological finding, and all of them underwent surgical operation.
Aneurysms were always treated by trapping, with aneurysmectomy in one case, but no distal extra-
intracranial (EC-IC) bypass was performed. In two cases, the histological examination of the aneurysm's
wall evidenced signs of subintimal dissection with widespread disruption of the internal elastic lamina and
media with neointima formation and intramural hemorrhage. Although bleeding is an uncommon presenting
sign of SDAs, they should be suspected in young people showing hemorrhage at CT scan. Early surgical
treatment and, if possible, preoperative neuroimaging evaluation of intracranial vessels should be performed
to reduce the mortality in these patients despite a higher postoperative morbidity.
• From a technical point of view, surgical trapping of the aneurysm seems to be a reasonable treatment
strategy especially in an emergency basis. However, whenever possible, an EC-IC bypass could help
diminish the ischemic morbidity associated with these aneurysms.

19. •. 2011;51(11):777-80.
doi: 10.2176/nmc.51.777.
Dissecting aneurysm of the anterior temporal artery:
case report
Katsuya Umeoka1, Kazutaka Shirokane, Takayuki Mizunari, Shiro Kobayashi, Akira Teramoto
Affiliations
•PMID: 22123481
•DOI: 10.2176/nmc.51.777
• A 65-year-old woman presented a rare dissecting aneurysm of the anterior temporal artery (ATA)
manifesting as headache. CT and MRI revealed a mixed-density mass in the horizontal segment of the
middle cerebral artery. Emergent angiography demonstrated aneurysmal dilatation and a
thrombosed mass in the sylvian fissure. Infectious aneurysm was excluded.
• She underwent emergent surgery to reduce the risk of repeated infarction and hemorrhage. The distal
side of the ATA manifested occlusive changes suggestive of arterial dissection. The proximal side of
the ATA was ligated and the lesion was excised. Histological examination confirmed that the
aneurysmal dilatation was attributable to arterial dissection due to disruption of the internal elastic
lamina.
• Distal dissecting aneurysms may occur in the absence of infectious disease. We recommend that
ruptured distal dissecting aneurysms be treated surgically in the acute stage immediately after
detection.

20.  Lin et al. successfully used overlapping Pipeline embolization devices (Medtronic)
with coils to treat an M1 dissecting aneurysm, and the long-term follow-up outcome
was favorable.
 In a study by Lozupone et al.comprising 17 patients, Pipeline embolization devices
were implanted in the treatment of 4 ruptured MCADAs. Two of the patients received
adjunctive coil embolization, 1 patient died because of complications of SAH, the
remaining 3 patients did not report any episodes of rebleeding, and no recorded clinical
complications were directly correlated to the flow diverter implant.

21. Conclusion
• Dissection of MCA rarely causes hemorrhagic manifestation even in young. In the
absence of other common causes of ICH in a young, dissection should be a
diagnostic consideration and angiography of intracranial arteries can be very
informative.
• A dissecting aneurysm may be one of the important causes of SAHs of unverified
origin. Although bleeding is an uncommon presenting sign of an SDA, it should
be included in the differential diagnosis when a saccular aneurysm is excluded in
patients showing subarachnoid or intracerebral hemorrhage.
• Endovascular treatment for MCADAs is a viable option with positive clinical and
angiographic results.

22. ThankYou!