Introduction Arterial dissections may be spontaneous or related to trauma, and patients with certain conditions, such as fibromuscular dysplasia or collagen vascular diseases, may be more pre-disposed to develop dissections. Arterial dissections in the intracranial vasculature are relatively rare and are less likely to be traumatic. When they do occur, they may lead to ischemic or embolic symptoms when there is a dissection flap or stenosis, or to subarachnoid hemorrhage or discovery of a non-ruptured, dissecting intracranial aneurysm.
Methods This was a retrospective analysis of a prospectively collected database of patients with intracranial arterial dissections, who were treated with intracranial stents by a single operator over 11 years, without or with coil embolization. Patient presentation, procedural results, type of stent, clinical outcome, and delayed imaging findings were reviewed. In cases of dissection with an intimal flap, stenting alone was performed. In patients with dissecting aneurysms, a stent was used in all cases, and only those cases that had a significant saccular component had the placement of coils, in addition to the intracranial stent.
Results A total of 49 patients were treated with intracranial arterial dissections. 19 of the patients presented with a dissection flap and arterial narrowing, 27 presented with a dissecting aneurysm (14 with subarachnoid hemorrhage and 13 with non-ruptured aneurysms), and three patients had a dissecting aneurysm and vessel narrowing. The average patient age was 34 years of age. The dissection location included 21 intracranial internal carotid artery (ICA), 12 vertebral artery, 6 posterior cerebral artery, 5 middle cerebral artery, 4 basilar artery, and 1 anterior cerebral artery. Patients were more likely to present with subarachnoid hemorrhage with ICA or vertebral artery dissections, and patients were more likely to present with ischemic symptoms with middle cerebral artery or basilar artery dissections. There were two thromboembolic complications (4%) related to the embolization procedure, there was one subsequent re-hemorrhage (2%) in a patient with a ruptured, blister-type, dissecting ICA aneurysm, and 1 groin access complication. Of the 30 patients who had an associated dissecting aneurysm, imaging follow-up was available in 25 patients. Of these, the recurrence rate was 20% (5 aneurysms), and all five were re-treated.
Conclusions Stenting without or with coils is an effective treatment option for patients with intra-cranial arterial dissections. We recommend treatment in patients with dissection flaps that are enlarging on imaging or refractory to medical therapy, and in patients with dissecting intracranial aneurysms, due to the high rate of subarachnoid hemorrhage. Our overall complication rate was 8% for treatment, and there was a high propensity for aneurysm re-growth, with a 20% re-treatment rate.
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Disclosures M Alexander: Codman Neurovascular, Stryker Neurovascular. A Choulakian: None. A Chowdhary: None. W Schievink: None.
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