Intracranial dissecting aneurysms of the posterior circulation

Report of six cases and review of the literature

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✓ Dissecting aneurysms of the intracranial posterior circulation are unusual lesions that affect otherwise healthy young adults, are difficult to diagnose and manage, and carry a high morbidity and mortality rate. Headache in the suboccipital-posterior cervical region is the most common presenting symptom. The dissection usually occurs between the intima or internal elastic lamina and the media; subadventitial dissection does occur and accounts for the infrequent finding of subarachnoid hemorrhage. A deficit in the inner layers of the vessel is the proposed source of dissection. The angiographic features are inconsistent, although an irregularly narrowed arterial segment with proximal and/or distal dilatation are typical findings. Depending on the location of the dissection, the surgical options are: ligation, trapping, or reinforcement of exposed abnormal portions of the vessel. Anticoagulation therapy is not indicated in the management of this lesion.

Article Information

Address reprint requests to: Mitchel S. Berger, M.D., c/o The Editorial Office, Department of Neurological Surgery, 350 Parnassus Avenue, Suite 807, San Francisco, California 94117.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 1. Right vertebral angiograms, anteroposterior (left) and lateral (right) views, showing an irregularly shaped, partially thrombosed dissecting aneurysm at the right vertebrobasilar junction (arrows).

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    Case 2. Left vertebral angiograms, anteroposterior (left) and lateral (right) views. Diffuse areas of vasospasm were present on the left vertebral (arrows) and basilar (small arrowheads) arteries, and there was a focal enlargement arising at the origin of the posterior inferior cerebellar artery on the right (large arrowheads).

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    Case 2. Anteroposterior left vertebral angiogram showing a large vertebral aneurysm (arrowhead). The dissecting aneurysm of the origin of the posterior inferior cerebellar artery seen previously is unchanged (arrow).

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    Case 3. Anteroposterior (left) and lateral (right) views of the left vertebral angiograms showing diffuse fusiform dilation of the distal basilar artery and both proximal posterior cerebral arteries (arrowheads). The dissection also involves the right superior cerebellar artery (arrows).

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    Case 3. Anteroposterior view of the distal vertebrobasilar region showing progression of the lesion to involve the right posterior cerebral artery distal to its junction with the posterior communicating artery (P2) (arrows).

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    Case 4. Anteroposterior (left) and lateral (right) views of the left vertebral angiograms showing a diffuse, irregularly shaped dissecting aneurysm of the temporal branch of the left posterior cerebral artery (arrows).

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    Summary of 36 previously reported cases of vertebrobasilar dissection*

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