Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery

Clinical article

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  • 1 Department of Radiology, Yonsei University College of Medicine, Severance Hospital, Seoul;
  • 2 Department of Radiology, Soonchunhyang University, Bucheon Hospital, Bucheon;
  • 3 Department of Neurosurgery, Catholic University College of Medicine;
  • 4 Departments of Radiology and
  • 6 Neurosurgery, Kyung Hee University College of Medicine; and
  • 5 Departments of Radiology and
  • 7 Neurosurgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
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Object

A ruptured dissecting aneurysm of the vertebrobasilar artery (VBA-DA) is a well-known cause of acute subarachnoid hemorrhage (SAH) with a high rate of early rebleeding. Internal trapping of the parent artery, including the dissected segment, is one of the most reliable techniques to prevent rebleeding. However, for a ruptured VBA-DA not suitable for internal trapping, the optimal treatment method has not been well established. The authors describe their experience in treating ruptured VBA-DAs not amenable to internal trapping of the parent artery with stent-assisted coil embolization (SAC) followed by a stent-within-a-stent (SWS) technique.

Methods

Eleven patients—6 men and 5 women with a mean age of 48 years and each with a ruptured VBA-DA not amenable to internal trapping of the parent artery—underwent an SAC-SWS between November 2005 and October 2007. The feasibility and clinical and angiographic outcomes of this combined procedure were retrospectively evaluated.

Results

The SAC-SWS was successful without any treatment-related complications in all 11 patients. Immediate posttreatment angiograms revealed complete obliteration of the DA sac in 3 patients, near-complete obliteration in 7, and partial obliteration in 1. One patient died as a direct consequence of the initial SAH. All 10 surviving patients had excellent clinical outcomes (Glasgow Outcome Scale Score 5) without posttreatment rebleeding during a follow-up period of 8–24 months (mean follow-up 15 months). Angiographic follow-up at 6–12 months after treatment was possible at least once in all surviving patients. Nine VBA-DAs showed complete obliteration; the other aneurysm, which had appeared partially obliterated immediately after treatment, demonstrated progressive obliteration on 2 consecutive follow-up angiography studies. There was no in-stent stenosis or occlusion of the branch or perforating vessels.

Conclusions

The SAC-SWS technique seems to be a feasible and effective reconstructive treatment option for a ruptured VBA-DA. The technique may be considered as an alternative therapeutic option in selected patients with ruptured VBA-DAs unsuitable for internal trapping of the parent artery.

Abbreviations used in this paper: BA = basilar artery; DA = dissecting aneurysm; GOS = Glasgow Outcome Scale; ICA = internal carotid artery; PICA = posterior inferior cerebellar artery; SAC = stent-assisted coil embolization; SAH = subarachnoid hemorrhage; SWS = stent-within-a-stent; VA = vertebral artery; VBA = vertebrobasilar artery.

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Contributor Notes

Address correspondence to: Byung Moon Kim, M.D., Department of Radiology, Yonsei University College of Medicine Severance Hospital, 250 Seongsanno, 120-752, Seoul, Korea. email: bmoon21@hanmail.net.
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