Multimodal treatment of ruptured dissecting aneurysms of the vertebral artery during the acute stage

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Object. The goal of this study was to implement an algorithm for and assess the multimodal (endovascular and microsurgical) treatment of patients with ruptured dissecting aneurysms of the vertebral artery (VA) during the acute stage.

Methods. During a 4-year period, the authors treated 19 ruptured dissecting aneurysms of the VA during the acute stage, within 3 days after the hemorrhage. Factors guiding management decisions were tolerance of the test occlusion and the site of the dissection. The algorithm takes into account these factors to select among treatment options, that is, trapping of the VA with Guglielmi Detachable Coils (GDCs); trapping of the VA and revascularization of the posterior inferior cerebellar artery (PICA); trapping of the VA and VA—posterior cerebral artery (PCA) anastomosis; and trapping of the VA, VA—PCA anastomosis, and revascularization of the PICA. Of the 15 aneurysms without PICA involvement, 14 were treated by trapping of the VA with GDCs and one by trapping of the VA and a VA—PCA bypass. The other four aneurysms with PICA involvement were treated by VA trapping and PICA revascularization. There was no episode of recurrent hemorrhage or ischemia during the posttreatment follow-up period. Although lateral medullary syndrome developed as a permanent complication in one patient, a good recovery was made by the other 18 patients by 6 months after the ictus.

Conclusions. The factors that determine the appropriate treatment for ruptured dissecting aneurysms of the VA are tolerance of a test occlusion and the site of dissection. Favorable patient outcomes can be achieved when this algorithm is used.

Article Information

Address reprint requests to: Jun-ichiro Hamada, M.D., Department of Neurosurgery, Kumamoto University School of Medicine, 1–1–1 Honjo, Kumamoto 860–856, Japan. email: jhamada@kaiju.medic.kumamoto-u.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Representative case in which the VA was trapped with GDCs. Upper Left: Left VA angiogram, anteroposterior view, revealing a dissecting aneurysm (arrows) arising from the left VA, distal to the origin of the PICA. Upper Right: Left VA angiogram, anteroposterior view, obtained during surgery demonstrating two microcatheters. One is located just distal to the end of the dissected segment (arrow), and the other one is situated distal to its beginning (arrowhead). Both borders of the dissecting aneurysm were simultaneously embolized with GDCs. Lower Left: Left VA angiogram, anteroposterior view, obtained after endovascular treatment revealing complete occlusion of the dissecting aneurysm and good filling of the PICA. The GDCs (arrows) are located at the proximal and distal borders of the aneurysm. Lower Right: Right VA angiogram, anteroposterior view, obtained after embolization demonstrating the absence of retrograde filling of the dissecting aneurysm.

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    Representative case in which the authors performed trapping of the VA and VA—PCA anastomosis. Left: Preoperative right VA angiogram, anteroposterior view, revealing a fusiform dissecting aneurysm (arrow) arising from the distal right VA. The left PICA is opacified because it is filled with contrast material from the left anterior inferior cerebellar artery. Right: Right VA angiogram, anteroposterior view, demonstrating occlusion of the dissecting aneurysm with excellent blood flow in the right PCA through the radial artery graft (arrowheads). Arrows indicate Sugita clips used for trapping.

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    Representative case in which the VA was trapped and the PICA reconstructed. Left: Preoperative right VA angiogram, anteroposterior view, revealing a dissecting aneurysm of the VA (arrow), which involves the PICA (arrowheads). Right: Postoperative right VA angiogram, anteroposterior view, demonstrating a patent VA—PICA anastomosis, which was created by interposing an STA graft (arrowheads). Arrows indicate Sugita clips used for trapping.

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    Algorithm for the management of ruptured dissecting aneurysms of the VA.

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