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LETTERS TO THE EDITOR
Year : 2022 | Volume
: 25
| Issue : 6 | Page : 1198-1200
Contemporary Management of Type III Cerebral Perforator Aneurysms
Prabodhini R Gadhari, Sharad B Ghatge
Department of Radiology, Division of Interventional Neuroradiology, Sir JJ Hospital and Grant Government Medical College, Mumbai, Maharashtra, India
Correspondence Address:
Prabodhini R Gadhari
B- 16, Pranam CHS, Chikuwadi, Shimpoli Road, Borivali West, Mumbai, Maharashtra - 400 092
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aian.aian_475_22
How to cite this article:Sir,
Incidence of cerebral perforator aneurysms is rare. They can lead to subarachnoid or intraparenchymal hemorrhage. Knowing about them is important to take appropriate decisions regarding their treatment strategies.
Objectives: 1. To understand the incidence of Type III cerebral perforator aneurysms as a cause of intraparenchymal or subarachnoid hemorrhage; 2. To know the methods of diagnosis and management.
Cerebral perforating arteries are small branches less than 1 mm in diameter supplying the para-median region of the brain stem. Aneurysms arising from them are extremely rare and difficult to detect because of their sub-millimeter size. Correct identification and treatment are necessary to prevent death. We systematically reviewed studies regarding type III perforator aneurysms, their presentation, the diagnosis, and the approach to management.
The perforating artery aneurysm arising away from the parent artery should be considered a separate entity from those arising from the parent artery adjacent to their origin or incorporating their origin. Satti et al. classified this subset of perforating artery aneurysm as type III.
Satti et al.[1] proposed a three-point classification.
Type I – the aneurysm arises from the basilar trunk adjacent to the perforating arterial branch but does not involve a perforating artery.
Type IIa – aneurysms incorporating the origin of the perforating arteries.
Type IIb – aneurysms having the perforating artery arising from the dome of the aneurysm.
Type III – fusiform aneurysms arising beyond the parent vessel (basilar artery).
This classification was extrapolated to include type III aneurysms arising from perforator branches of basilar or any other cerebral arteries.
We performed searches in PubMed and Google Scholar.
The database coverage was 1965 to present. The following keywords were used.
Cerebral perforating artery and aneurysms – 745 resultsPerforating artery or aneurysms – 184,004 resultsCerebral perforating arteries – 1946 resultsPerforator aneurysms – 2569 results.Inclusion criteria
Aneurysms with neck arising from perforator branches of cerebral arteries (Satti Type III).(2)Studies related to their diagnosis – radiological or post-surgeryStudies related to all treatment approaches.Full text of all eligible studies was retrieved. Studies were screened by two reviewers until concordance was achieved. Disagreements about eligibility were resolved through discussion.
Of 13 selected unique studies, nine were case reports, one was a review article with case series, one was a review article along with case reports, one was a cross-sectional observational study, and one was a prospective cohort study.
We reviewed an article published in this journal named “Basilar artery Perforator Aneurysms and their contemporary management.”[2] The results obtained from all other shortlisted studies were compiled in a tabular format [Supplementary Table 1].
The total cases from the selected articles are divided as per the treatment approach into three different groups, that is,
Endovascular treatment groupConservative treatment groupSurgical treatment group.The cases in each of the groups were compiled together in tables that summarized the data [Supplementary Table 2], [Supplementary Table 3], [Supplementary Table 4].
The majority of case reports had patients who initially presented with subarachnoid hemorrhage. Only two presented with intracerebral hemorrhage. In the majority, the cause of the perforator aneurysm was found to be idiopathic. In a few, patients were hypertensive.
Six of nine case reports revealed the requirement of repeat angiography.
Thirteen out of all search results were based on type III perforator aneurysms. Relevant data from a total of 98 cases were obtained from the selected 13 studies [Supplementary Table 1].
With regard to location of aneurysms, out of these 98 cases, three were type III aneurysms of middle cerebral artery perforators, two involved anterior cerebral artery perforators, 87 arose from perforators of the basilar artery or any of its branches. The data about exact location of the remaining six cases was not available.
Twenty cases were treated by surgical methods. Among these, surgical clipping was performed for five cases. The rest were treated by surgical resection/excision. Of these, permanent ischemic complication was noted in one case post surgery, and four cases showed transient ischemic complications.
A total of 37 cases were managed by an endovascular approach. Stenting (single stent/overlapping stent) was performed in 17 cases. Flow diversion was performed for eight. Flow diversion with stenting was done for one. Onyx occlusion was performed in two. Coiling was performed in three. The endovascular approach was attempted but failed in four. The perforator preserving technique was used in one. In six cases, ischemic complications were seen, and four cases showed transient ischemic attacks. One death occurred during the peri-operative period because of a rupture of the perforator artery.
A total of 41 cases were managed by a conservative approach. In six cases, ischemic complications occurred.
The summarized analysis of the reviewed studies indicates that a maximum number of cases of type III perforator aneurysms were treated by conservative management, out of which a lesser proportion showed ischemic complications.
A substantial number of cases were treated surgically, in which there was one permanent ischemic complication and a few transient complications, and the rest showed complete successful exclusion of the aneurysm.
Endovascular treatment was attempted in many cases, but failure to cannulate the perforator artery was noted in many cases. Ischemic complications were seen in a larger proportion of cases. Death was noted in one case.
It can be concluded that the conservative approach showed successful results in a large number of cases with a lesser rate of complications (14.6%). None showed life-threatening or serious complications.
The surgical group showed ischemic complications in 25% of cases and can be considered the next best mode of management.
The endovascular group, however, showed more failures as well as complications including death compared to the other two treatment groups. The complication rate is 40.5%.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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