1. Vertebrobasilar Dolichoectatic and Fusiform Intracranial Aneurysms: Proposal of a Prospective Italian Register on Natural History and New Treatment Modalities in the Era of the Flow Diverters Technology C.Bortolotti °, C.Sturiale°, M.Dall’Olio, C.Princiotta, L.Cirillo, M.Leonardi, R.Menozzi*,L.Lanterna ^, F.Calbucci°, A.Andreoli° Units of Neurosurgery° and Neuroradiology, Bellaria-Maggiore Hospitals, Bologna, *Unit of Intervetional Neuroradiology Ospedale Maggiore,Parma; ^Unit of Neurosurgery, Ospedali Riuniti, Bergamo, Italy

2. What does Vertebrobasilar Non Saccular Intracranial Aneurysms mean (NIA) ? Probably may be different manifestations of the same underlying disorder with a peculiar pathogenesis and enlarging mechanism Chronic arterial wall dissection

3. Vertebrobasilar NIA are rare and have been designated by numerous terms 1.Nonatherosclerotic cerebral Fusiform and Dissecting aneurysms 2.Chronically growing basilar artery 3.Megadolichobasilar anomaly 4.Giant serpentine aneurysms 5.Dolichoectatic aneurysms 6.Fusiform aneurysms 7.Dolichoectatic intracranial Dissecting aneurysms

4. Pathological Classification

5. ARTICOLO Class Mizutani

6. 1.Internal Elastic Lamina fragmentation 2.Intimal thickening

7. Classification

8. Dolichoectasia -uniform aneurysmal dilatation of an artery greater than 1.5 times normal involving either the entire basilar or vertebral or both with any degree of tortuosity

9. Fusiform- aneurysmal dilatation 1.5 times normal diameter without a definable neck Involving a portion of an arterial segment (either the vertebral or basilar) with any degree of tortuosity.

11. Transition -uniform dilatation of an artery greater than 1.5 time normal involving the vertebral, basilar or both with a superimposed dilatation of a portion of the Involved arterial segment

13. Clinical Presentation

14. Brainstem compression

15. Brainstem infarction

16. Subarachnoid hemorrhage Courtesely provided by Dr L. Lanterna, Division of Neurosugery, Bergamo,Italy

18. 3 days later……

19. Natural History Data from 159 pz with VBNIA seen at Mayo Clinic between 1989 and 2001 were reviewed.

20. Mass effect (22%) Cerebral infarction (28%) Hemorragic 3% unrelated symptoms 40 % unclear 7% Clinical Presentation and Natural History 65 pz (40 %) died during follow-up. The median survival was 7.8 years. Death was aneurysm-related in 31 pz (48%)

22. Vertebrobasilar NIA managment Vertebrobasilar NIA aneurysms demonstrated on serial imaging enlarged, and this growth was associated with significant morbidity and death. Significant risk factors for aneurysm enlargement included symptomatic compression at the initial diagnosis, transitional and fusiform types, and initial lesion diameter (≥10 mm).

23. Formidable treatment challenges for Vascular Neurosurgeons and Interventional Neuroradiologists DAVID and GOLIATH

24. Surgical Approach Dolichoectatic and Fusiform aneurysms lack a definable neck that can be easily clipped while preserving the afferent end efferent vessels Consequently,they are especially hard to treat surgically In addition, the parent vessels is either cirumferentially Involved by the aneurysmal dilatation or ends in a large thrombosed sac with distal branches arising from the base of the lesion

25. Clip reconstruction of the parent artery (Aneurysmorrhaphy and thrombectomy ) associated or not with cardiac standstill or Adenosine –induced asystolia. Parent Artery occlusion (previous BTO): 1.Inflow occlusion (proximal or Hunterian ligation) 2.Outflow occlusion (distal occllusion) 3.Both (trapping +/- bypass) Cerebral Revascularization Surgical Approach

27. Ponce FA, Spetzler RF, et al: Cardiac standstill for cerebral aneurysms in 103 patients: un up-date on the experience at the Barrow Neurological Institute. Clinical article. J Neurosurg. In Press. Large and giant aneurysms: 90 % in the posterior circulation Combined morbidity-mortality 32 % Perioperative mortality: 14% At the follow-up (mean period 9.7 years) 65 pz (63%) were considered to have “favorable outcome” GOS 4-5

28. Endovascular Approach Occlusion of dominant - bilateral vertebral arteries or proximal BA sacrifice +/- preocclusion arterial bypass Artery coils trapping Deconstructive approach Stent Assisted Coil- embolization Sole stenting techniques Constructive approach With flow reversal in the “dissected BA”

29. Transition type aneurysms (vertebrobasilar dolichoectasia with a superimposed aneurysmal dilatation) is a progressive arteriopathy in which, contrary to conventional thinking, aneurysms growth and subsequent expansion may occur Independent of hemodynamic stress. Consequently a complete Hunterian proximal ligation with a pure hemodynamic impact on the aneurysms is not always able to cure the peculiar features of this kind of aneurysms: An Entire Wall Vessel Disease.

31. Flow Diverters Stents with densely woven meshes Pipeline Ev3, USA BALT Europe

32. “Endothelial prothesis” By working like a “Jack” or intravacsular band-aid

33. Type 3 These stents share the propriety of forming hig-coverage meshs once expandend that cover the neck, inducing re-endhotelization and shrinkage of the IMH and thrombus by flow redistribution in the parent vessel which is maintain patent.

34. September,2010 11 pz

36. Stroke, October 2010

37. CASE 1 A 69-YEAR-OLD-MAN 3 MONTH HISTORY OF PROGRESSIVE HEADACHE AND BRAINSTEM COMPRESSION WITH LIQUIDS DISPHAGYA NEUROLOGICAL EXAMINATION REVEALED ATAXIA AND MILD MOTOR INCORDINATION CEREBRAL CT, CTA and AGF

40. A Silk, 4.5 x 40 mm

43. 1 month later Clinically unchanged

44. CASE 2 58-year-old-man Headache and gait ataxia

46. 4 MONTHS F-U Clinical improvement

47. CASE 3 67-YEAR-OLD-MAN FATHER DIED FOR RUPTURED CEREBRAL ANEURYSM VERTIGO AND ATAXIA

48. Courtesely provided by Dr.R. Menozzi, Parma Italy

50. After 60 days

51. 4 months later Clinical Improvement

52. CASE 4

54. POST PRE

55. CT AT ADMISSION

56. CT F-U AFTER 2 DAYS

57. CT F-U AT 9 DAYS

59. FINAL CONSIDERATIONS Fusiform and dolichoectatic vertebrobasilar artery aneurysms are very rare vascular abnormalities (0,7% of the posterior circulation aneurysms) with a high propency to enlarge and rupture. Little is known about the natural history and current data are based largely on small series. The constitution of a Prospective Register on the natural history and new treatment modalities in the light of the new endovascular technologies could be very useful to identify a definitive advancement in the treatment of this disease.

60. List of participants Dr.ssa Elisa Ciceri, Unit of Interventional Neuroradiology, Istituto Nazionale Neurologico “C.Besta”,Milano,Italy Dr Roberto Menozzi, Unit of Interventional Neuroradiology, Ospedale Maggiore, Parma Italy Dr Luigi Lanterna, Unit of Neurosurgery, Ospedali Riuniti Bergamo,Italy Dr Fulvio Tartara, Division of Neurosurgery, Ospedale Le Molinette, Torino, Italy Dr Andrea Cardia, Unit of Neurosurgery, IRCCS,Istituto Galeazzi,Milano,Italy

62. Medical Therapy (without Plavix): Pre-procedural: 3 days in advance Tiklid 250 X 2 Ascriptin 300 mg X 1 Lansox 30 mg X 2 Medical Therapy (with Plavix): Pre-procedural: 3 days in advance Plavix 75 mg X 1 Asa 100 mg X1 Lansox 30 mg X 2