Clinical StudyManagement of ruptured and unruptured intracranial vertebral artery dissecting aneurysms
Introduction
Dissecting aneurysms (DA) of the vertebral artery (VA) (VADA) were considered rare, but are being reported with increasing frequency as the etiology for subarachnoid hemorrhage (SAH) or brainstem ischemia.1, 2, 3 Yamaura et al. reported that VADA account for 28% of VA and 11% of posterior circulation aneurysms.4 The precise incidence of VADA remains unclear and is underestimated because some patients die immediately following severe SAH, and are not included in statistical analyses. In addition, some patients are misdiagnosed. VADA exhibit male dominance and symptoms commonly occur between the ages of 30 and 50 years,1, 4 although the cause of these aneurysms remains uncertain. In a previous report, three of seven patients were conservatively managed and subsequently died following re-hemorrhage.5 In another study, there was a high re-bleeding rate (71.4%), which was associated with 47% mortality in patients without surgical management.6 These results have shown the need for intervention, including open surgery consisting of proximal clipping, external trapping, aneurysmal sac clipping, wrapping, and vessel anastomosis. However, the use of open surgery remains restricted because of procedural difficulty and its association with a high rate of post-operative lower cranial nerve (LCN) palsy.1, 2, 4 Recently endovascular treatment has been reported as effective in patients with VADA and includes several techniques, including proximal occlusion of the parent artery, internal trapping, stent-assisted coil embolization, and stent-only placement.3, 5, 7, 8, 9, 10 Although the number of studies on VADA is increasing, optimal management strategies remain controversial. The present study describes the multi-modal treatment of 12 consecutive patients with intracranial VADA.
Section snippets
Patients and methods
From December 2005 to May 2010, 12 consecutive patients with VADA were admitted to Qilu Hospital of Shandong University. Patients with VADA arising from extracranial VA, as well as dissections confined to the posterior inferior cerebellar artery (PICA) or associated with the basilar artery, were excluded. Clinical presentation, serial radiological imaging, diagnosis, management, and outcomes of these patients were analyzed.
The ratio of male to female patients with VADA was 1:1, and patients
Radiological findings
Based on the results of CT scans, nine of 12 patients presented with SAH of a ruptured aneurysm, two of whom experienced abrupt re-hemorrhage, and three patients had no history of SAH. Magnetic resonance results showed an intramural hematoma in one patient. All aneurysms appeared irregular or with fusiform dilation, one exhibited a double-lumen sign, and four showed retention of contrast medium. No pearl-string sign was observed.
Eight of the 12 lesions were located on the right side and four on
Pathology and diagnosis
Although the definitive cause of VADA remains unknown, some predisposing factors, such as hypertension, arteriosclerosis, intrinsic disorders of the vessel wall, contraceptive use, and trauma, have been described. The VA wall is composed of three layers: the intima with the internal elastic lamina, the media, and the adventitia. Dissection typically implies a tear in the wall, which results in intrusion of blood into the three layers, and the intima and media are often involved. Histologically,
Conclusions
Ruptured VADA should be actively treated, because of the high risk of re-bleeding and subsequent mortality. Although each treatment method exhibits advantages and disadvantages, the management strategy must be developed according to the individual patient’s clinical condition and imaging study results. Endovascular treatment, which includes several methods, is the first choice for most patients. Stent-assisted coiling is an appropriate method for VADA and provides the following advantages:
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Updates in the Management of Cerebral Infarctions and Subarachnoid Hemorrhage Secondary to Intracranial Arterial Dissection: A Systematic Review
2019, World NeurosurgeryCitation Excerpt :Patients who are treated conservatively for SAH have been found to have poor clinical outcomes, resulting from frequent rebleeds.35,84 Ruptured dissections are unstable and have a tendency to rebleed.3,16,79 Studies on the treatment of posterior circulation IADs presenting with SAH3,16,46,49,85 report high mortality and poor outcomes.
Long-term follow-up study of 35 cases after endovascular treatment for vertebrobasilar dissecting aneurysms
2015, Clinical Neurology and NeurosurgeryCitation Excerpt :It has been reported that the recurrent rates of SAH and death are as high as 71.4% and 47%, respectively, in untreated VBDA patients [40]. Therefore, VBDA patients with SAH should be treated as early as possible to prevent recurrent hemorrhage [41]. In one patient who suffered two instances of SAH, the first follow-up angiography showed a negative result, but the second DSA detected a dissecting aneurysm at the superior cerebellar artery.
Occipital artery-posterior inferior cerebellar artery bypass for the treatment of aneurysms arising from the vertebral artery and its branches
2014, World NeurosurgeryCitation Excerpt :We have performed PICA revascularization to minimize the possibility of ischemic complication for all our patients with a VA dissecting aneurysm with involving PICA origin. We contend that trapping of the dissecting segment of the VA with revascularization of the PICA is one of the optimal treatment methods for aneurysms arising from the VA including the VA-PICA junction based on our own experiences and previous reports (24, 40). The Pipeline Embolization Device (Chestnut Medical, Menlo Park, California) is a flow diverter that was designed to treat intracranial aneurysms with endoluminal parent artery reconstruction.
Dissecting Aneurysm of M3 Portion of the Middle Cerebral Artery after Drainage of Hypertensives Intracerebral Hemorrhage: A Case Report
2022, Journal of Biological Regulators and Homeostatic Agents
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These authors contributed equally to this work.