Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery.
Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms.
The post–coil embolization patients underwent V3–posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V3–V4 or V4–V4 bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable.
Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V3-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.
INCLUDE WHEN CITING Published online February 5, 2016; DOI: 10.3171/2015.8.JNS15362.
Ahn JY, , Han IB, , Kim TG, , Yoon PH, , Lee YJ, & Lee BH, et al.: Endovascular treatment of intracranial vertebral artery dissections with stent placement or stentassisted coiling. AJNR Am J Neuroradiol 27:1514–1520, 2006
Batjer HH, & Purdy PD: Enlarging thrombosed aneurysm of the distal basilar artery. Neurosurgery 26:695–700, 1990
Chang SD, , Marks MP, & Steinberg GK: Recanalization and rupture of a giant vertebral artery aneurysm after hunterian ligation: case report. Neurosurgery 44:1117–1121, 1999
Fiorella D, , Hsu D, , Woo HH, , Tarr RW, & Nelson PK: Very late thrombosis of a pipeline embolization device construct: case report. Neurosurgery 67:onsE313–onsE314, 2010
Fiorella D, , Kelly ME, , Albuquerque FC, & Nelson PK: Curative reconstruction of a giant midbasilar trunk aneurysm with the pipeline embolization device. Neurosurgery 64:212–217, 2009
Fiorella D, , Woo HH, , Albuquerque FC, & Nelson PK: Definitive reconstruction of circumferential, fusiform intracranial aneurysms with the pipeline embolization device. Neurosurgery 62:1115–1121, 2008
Halbach VV, , Higashida RT, , Dowd CF, , Barnwell SL, , Fraser KW, & Smith TP, et al.: The efficacy of endosaccular aneurysm occlusion in alleviating neurological deficits produced by mass effect. J Neurosurg 80:659–666, 1994
He M, , Zhang H, , Lei D, , Mao BY, , You C, & Xie XD, et al.: Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms. J Neurosurg 110:418–426, 2009
Iihara K, , Murao K, , Sakai N, , Soeda A, , Ishibashi-Ueda H, & Yutani C, et al.: Continued growth of and increased symptoms from a thrombosed giant aneurysm of the vertebral artery after complete endovascular occlusion and trapping: the role of vasa vasorum. Case report. J Neurosurg 98:407–413, 2003
Iihara K, , Sakai N, , Murao K, , Sakai H, , Higashi T, & Kogure S, et al.: Dissecting aneurysms of the vertebral artery: a management strategy. J Neurosurg 97:259–267, 2002
Inoue A, , Kohno K, , Takechi A, , Kohno K, , Matsushige T, & Takeda T: Bilateral vertebral artery dissecting aneurysm with subarachnoid hemorrhage treated with staged bilateral vertebral artery coil occlusion: a case report. Surg Neurol 70:319–322, 2008
Kakino S, , Ogasawara K, , Kubo Y, , Otawara Y, , Tomizuka N, & Suzuki M, et al.: Treatment of vertebral artery aneurysms with posterior inferior cerebellar artery-posterior inferior cerebellar artery anastomosis combined with parent artery occlusion. Surg Neurol 61:185–189, 2004
Katsuno M, , Mizunari T, , Kobayashi S, , Takahashi H, & Teramoto A: Rupture of a vertebral artery dissecting aneurysm developing immediately after trapping of a dissecting aneurysm on the contralateral vertebral artery: case report. Neurol Med Chir (Tokyo) 49:468–470, 2009
Katsuno M, , Tanikawa R, , Uemori G, , Kawasaki K, , Izumi N, & Hashimoto M: Occipital artery-to-posterior inferior cerebellar artery anastomosis with multiple-layer dissection of suboccipital muscles under a reverse C-shaped skin incision. Br J Neurosurg 29:401–405, 2015
Kawashima M, , Matsushima T, , Inoue T, , Mineta T, , Masuoka J, & Hirakawa N: Microvascular decompression for glossopharyngeal neuralgia through the transcondylar fossa (supracondylar transjugular tubercle) approach. Neurosurgery 66:6 Suppl Operative 275–280, 2010
Klisch J, , Turk A, , Turner R, , Woo HH, & Fiorella D: Very late thrombosis of flow-diverting constructs after the treatment of large fusiform posterior circulation aneurysms. AJNR Am J Neuroradiol 32:627–632, 2011
Kobayashi N, & Hiroyasu K: Reconstruction of the basilar arterial system: Methods of high-flow bypass in posterior cranial fossa. Surg Cereb Stroke (Jpn) 27:270–276, 1999
Koh JS, , Ryu CW, , Lee SH, , Bang JS, & Kim GK: Bilateral vertebral-artery-dissecting aneurysm causing subarachnoid hemorrhage cured by staged endovascular reconstruction after occlusion. Cerebrovasc Dis 27:202–204, 2009
Kono K, , Shintani A, , Fujimoto T, & Terada T: Stent-assisted coil embolization and computational fluid dynamics simulations of bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage: case report. Neurosurgery 71:E1192–E1201, 2012
Kubota H, , Tanikawa R, , Katsuno M, , Izumi N, , Noda K, & Ota N, et al.: Vertebral artery-to-vertebral artery bypass with interposed radial artery or occipital artery grafts: surgical technique and report of three cases. World Neurosurg 81:202.e1–202.e8, 2014
Kubota H, , Tanikawa R, , Katsuno M, , Noda K, , Ota N, & Miyata S, et al.: Reconstruction of intracranial vertebral artery with radial artery and occipital artery grafts for fusiform intracranial vertebral aneurysm not amenable to endovascular treatment: technical note. Acta Neurochir (Wien) 155:1517–1524, 2013
Kurata A, , Ohmomo T, , Miyasaka Y, , Fujii K, , Kan S, & Kitahara T: Coil embolization for the treatment of ruptured dissecting vertebral aneurysms. AJNR Am J Neuroradiol 22:11–18, 2001
Lee KC, , Joo JY, , Lee KS, & Shin YS: Recanalization of completely thrombosed giant aneurysm: case report. Surg Neurol 51:94–98, 1999
Lylyk P, , Miranda C, , Ceratto R, , Ferrario A, , Scrivano E, & Luna HR, et al.: Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery 64:632–643, N6, 2009
Martin AR, , Cruz JP, , Matouk CC, , Spears J, & Marotta TR: The pipeline flow-diverting stent for exclusion of ruptured intracranial aneurysms with difficult morphologies. Neurosurgery 70:1 Suppl Operative 21–28, 2012
Matsushima T, & Fukui M: [Lateral approaches to the foramen magnum: with special reference to the transcondylar fossa approach and the transcondylar approach.]. No Shinkei Geka 24:119–124, 1996. (Jpn)
Matsushima T, , Kawashima M, , Masuoka J, , Mineta T, & Inoue T: Transcondylar fossa (supracondylar transjugular tubercle) approach: anatomic basis for the approach, surgical procedures, and surgical experience. Skull Base 20:83–91, 2010
Mitchell B, , Momin E, , Jou LD, , Shaltoni H, , Morsi H, & Mawad M: Extensive bilateral vertebral artery remodeling following treatment of dissection using pipeline embolic device. J Vasc Interv Neurol 7:5–8, 2014
Mizutani T, , Aruga T, , Kirino T, , Miki Y, , Saito I, & Tsuchida T: Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 36:905–913, 1995
Nagahiro S, , Takada A, , Goto S, , Kai Y, & Ushio Y: Thrombosed growing giant aneurysms of the vertebral artery: growth mechanism and management. J Neurosurg 82:796–801, 1995
Nashimoto T, , Saito T, , Kurashima A, , Yamashita S, & Honma J: [Case of bilateral vertebral artery dissecting aneurysm presenting with subarachnoid hemorrhage.]. No Shinkei Geka 37:381–385, 2009. (Jpn)
Nishimu YA, , Ikeda A, , Sugita R, , Maeda K, , Nakamua S, & Takerroto M, et al.: [Case of spontaneous bilateral VA dissecting aneurysm presenting with SAH.]. No Shinkei Geka 35:583–589, 2007. (Jpn)
Otawara Y, , Ogasawara K, , Ogawa A, & Kogure T: Dissecting aneurysms of the bilateral vertebral arteries with subarachnoid hemorrhage: report of three cases. Neurosurgery 50:1372–1375, 2002
Rabinov JD, , Hellinger FR, , Morris PP, , Ogilvy CS, & Putman CM: Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 24:1421–1428, 2003
Sakamoto S, , Ohba S, , Shibukawa M, , Kiura Y, , Okazaki T, & Arita K, et al.: Staged bilateral vertebral artery occlusion for ruptured dissecting aneurysms of the basilar artery: a report of 2 cases. Surg Neurol 64:456–461, 2005
Somekawa K, , Nagata K, , Kawamoto S, , Furuya H, , Tanioka D, & Isoo A: [Treatment for the ruptured bilateral vertebral dissecting aneurysms.]. No Shinkei Geka 30:321–325, 2002. (Jpn)
Sugita K, , Kobayashi S, , Takemae T, , Tanaka Y, , Okudera H, & Ohsawa M: Giant aneurysms of the vertebral artery. Report of five cases. J Neurosurg 68:960–966, 1988
Suh SH, , Kim BM, , Park SI, , Kim DI, , Shin YS, & Kim EJ, et al.: Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery. Clinical article. J Neurosurg 111:48–52, 2009
Swearingen B, & Heros RC: Fatal rupture of a thrombosed giant basilar artery aneurysm. Surg Neurol 23:299–302, 1985
Szikora I, , Berentei Z, , Kulcsar Z, , Marosfoi M, , Vajda ZS, & Lee W, et al.: Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol 31:1139–1147, 2010
Tanikawa R, , Sugimura T, , Hino K, , Izumi N, , Mitsui N, & Yamauchi T, et al.: Surgical application of skull base technique for EC-IC bypass to P2 segment. Surg Cereb Stroke (Jpn) 34:440–444, 2006
Wilkinson DA, , Wilson TJ, , Stetler WR, & Pandey AS: Subarachnoid haemorrhage with bilateral intracranial vertebral artery dissecting aneurysms treated by staged endovascular stenting. BMJ Case Rep 2013:bcr0320126002, 2013
Yeung TW, , Lai V, , Lau HY, , Poon WL, , Tan CB, & Wong YC: Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 116:882–887, 2012
Yoon SM, , Shim JJ, , Kim SH, & Chang JC: Bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage treated by staged coil trapping and covered stents graft. J Korean Neurosurg Soc 51:155–159, 2012
| All Time | Past Year | Past 30 Days | |
|---|---|---|---|
| Abstract Views | 97 | 79 | 17 |
| Full Text Views | 1834 | 138 | 7 |
| PDF Downloads | 1380 | 141 | 14 |
| EPUB Downloads | 0 | 0 | 0 |