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

Contributor Notes

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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References
  • 1.

    Aoki NSakai T: Rebleeding from intracranial dissecting aneurysm in the vertebral artery. Stroke 21:162816311990Aoki N Sakai T: Rebleeding from intracranial dissecting aneurysm in the vertebral artery. Stroke 21:1628–1631 1990

    • Search Google Scholar
    • Export Citation
  • 2.

    Berger MSWilson CB: Intracranial dissecting aneurysms of the posterior circulation. Report of six cases and review of the literature. J Neurosurg 61:8828941984Berger MS Wilson CB: Intracranial dissecting aneurysms of the posterior circulation. Report of six cases and review of the literature. J Neurosurg 61:882–894 1984

    • Search Google Scholar
    • Export Citation
  • 3.

    Chater N: Neurosurgical extracranial-intracranial bypass for stroke: with 400 cases. Neurol Res 5:191983Chater N: Neurosurgical extracranial-intracranial bypass for stroke: with 400 cases. Neurol Res 5:1–9 1983

    • Search Google Scholar
    • Export Citation
  • 4.

    Friedman AHDrake CG: Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60:3253341984Friedman AH Drake CG: Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60:325–334 1984

    • Search Google Scholar
    • Export Citation
  • 5.

    Halbach VVHigashida RTDowd CFet al: Endovascular treatment of vertebral artery dissections and pseudoaneurysms. J Neurosurg 79:1831911993Halbach VV Higashida RT Dowd CF et al: Endovascular treatment of vertebral artery dissections and pseudoaneurysms. J Neurosurg 79:183–191 1993

    • Search Google Scholar
    • Export Citation
  • 6.

    Hamada JITodaka TYano Set al: Vertebral artery-posterior inferior cerebellar artery bypass with a superficial temporal artery graft to treat aneurysms involving the posterior inferior cerebellar artery. J Neurosurg 96:8678712002Hamada JI Todaka T Yano S et al: Vertebral artery-posterior inferior cerebellar artery bypass with a superficial temporal artery graft to treat aneurysms involving the posterior inferior cerebellar artery. J Neurosurg 96:867–871 2002

    • Search Google Scholar
    • Export Citation
  • 7.

    Hunt WEHess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14201968Hunt WE Hess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20 1968

    • Search Google Scholar
    • Export Citation
  • 8.

    Iihara KSakai NMurao Ket al: Dissecting aneurysms of the vertebral artery: a management strategy. J Neurosurg 97:2592672002Iihara K Sakai N Murao K et al: Dissecting aneurysms of the vertebral artery: a management strategy. J Neurosurg 97:259–267 2002

    • Search Google Scholar
    • Export Citation
  • 9.

    Ito MKinoshita ATakemoto Oet al: Superficial temporal artery to superior cerebellar artery anastomosis via the presigmoid retrolabyrinthine transtentorial approach. Surg Neurol 43:3603621995Ito M Kinoshita A Takemoto O et al: Superficial temporal artery to superior cerebellar artery anastomosis via the presigmoid retrolabyrinthine transtentorial approach. Surg Neurol 43:360–362 1995

    • Search Google Scholar
    • Export Citation
  • 10.

    Kitanaka CMorimoto TSasaki Tet al: Rebleeding from vertebral artery dissection after proximal clipping. Case report. J Neurosurg 77:4664681992Kitanaka C Morimoto T Sasaki T et al: Rebleeding from vertebral artery dissection after proximal clipping. Case report. J Neurosurg 77:466–468 1992

    • Search Google Scholar
    • Export Citation
  • 11.

    Kurata AOhmomo TMiyasaka Yet al: Coil embolization for the treatment of ruptured dissecting vertebral aneurysms. AJNR 22:11182001Kurata A Ohmomo T Miyasaka Y et al: Coil embolization for the treatment of ruptured dissecting vertebral aneurysms. AJNR 22:11–18 2001

    • Search Google Scholar
    • Export Citation
  • 12.

    Lylyk PCohen JECeratto Ret al: Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils. J Neurosurg 94:4274322001Lylyk P Cohen JE Ceratto R et al: Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils. J Neurosurg 94:427–432 2001

    • Search Google Scholar
    • Export Citation
  • 13.

    Mahmood ADujovny MTorche Met al: Microvascular anatomy of foramen caecum medullae oblongatae. J Neurosurg 75:2993041991Mahmood A Dujovny M Torche M et al: Microvascular anatomy of foramen caecum medullae oblongatae. J Neurosurg 75:299–304 1991

    • Search Google Scholar
    • Export Citation
  • 14.

    Mizutani TAruga TKirino Tet al: Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 36:9059131995Mizutani T Aruga T Kirino T et al: Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 36:905–913 1995

    • Search Google Scholar
    • Export Citation
  • 15.

    Mizutani TKojima HAsamoto Set al: Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms. J Neurosurg 94:7127172001Mizutani T Kojima H Asamoto S et al: Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms. J Neurosurg 94:712–717 2001

    • Search Google Scholar
    • Export Citation
  • 16.

    Sekhar LNDuff JMKalavakonda Cet al: Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients. Neurosurgery 49:6466592001Sekhar LN Duff JM Kalavakonda C et al: Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients. Neurosurgery 49:646–659 2001

    • Search Google Scholar
    • Export Citation
  • 17.

    Shrontz CDujovny MAusman JIet al: Surgical anatomy of the arteries of the posterior fossa. J Neurosurg 65:5405441986Shrontz C Dujovny M Ausman JI et al: Surgical anatomy of the arteries of the posterior fossa. J Neurosurg 65:540–544 1986

    • Search Google Scholar
    • Export Citation
  • 18.

    Wakhloo AKLanzino GLieber BBet al: Stents for intracranial aneurysms: the beginning of a new endovascular era? Neurosurgery 43:3773791998Wakhloo AK Lanzino G Lieber BB et al: Stents for intracranial aneurysms: the beginning of a new endovascular era? Neurosurgery 43:377–379 1998

    • Search Google Scholar
    • Export Citation
  • 19.

    Yamaura AWatanabe YSaeki N: Dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 72:1831881990Yamaura A Watanabe Y Saeki N: Dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 72:183–188 1990

    • Search Google Scholar
    • Export Citation
  • 20.

    Yamaura ITani EYokota Met al: Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Guglielmi detachable coils. J Neurosurg 90:8538561999Yamaura I Tani E Yokota M et al: Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Guglielmi detachable coils. J Neurosurg 90:853–856 1999

    • Search Google Scholar
    • Export Citation
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