Endovascular treatment of vertebral artery dissections and pseudoaneurysms

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✓ Sixteen patients with dissecting aneurysms or pseudoaneurysms of the vertebral artery, 12 involving the intradural vertebral artery and four occurring in the extradural segment, were treated by endovascular occlusion of the dissection site. Patients with vertebral fistulas were excluded from this study. The dissection was caused by trauma in three patients (two iatrogenic) and in the remaining 13 no obvious etiology was disclosed. Nine patients presented with subarachnoid hemorrhage (SAH), two of whom had severe cardiac disturbances secondary to the bleed. The nontraumatic dissections occurred in seven women and six men, with a mean age on discovery of 48 years. Fifteen patients were treated with endovascular occlusion of the parent artery at or just proximal to the dissection site. One patient had occlusion of a traumatic pseudoaneurysm with preservation of the parent artery. Four patients required transluminal angioplasty because of severe vasospasm produced by the presenting hemorrhage, and all benefited from this procedure with improved arterial flow documented by transcranial Doppler ultrasonography and arteriography.

In 15 patients angiography disclosed complete cure of the dissection. One patient with a long dissection of extracranial origin extending intracranially had proximal occlusion of the dissection site. Follow-up angiography demonstrated healing of the vertebral artery dissection but persistent filling of the artery above the balloons, which underscores the need for embolic occlusion near the dissection site. No hemorrhages recurred. One patient had a second SAH at the time of therapy which was immediately controlled with balloons and coils. This patient and one other had minor neurological worsening resulting from the procedure (mild Wallenberg syndrome in one and minor ataxia in the second).

Symptomatic vertebral artery dissections involving the intradural and extradural segments can be effectively managed by endovascular techniques. Balloon test occlusion and transluminal angioplasty can be useful adjuncts in the management of this disease.

Article Information

Address reprint requests to: Van V. Halbach, M.D., 505 Parnassus Avenue, L352, San Francisco, California 94143–0628.

© AANS, except where prohibited by US copyright law.

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    Case 12. A: Left vertebral arteriogram with a left subclavian injection, anteroposterior projection, demonstrating an ectatic left vertebral artery with a dissecting aneurysm arising at the C-6 level. B: Computerized tomography scan at the level of the dissection demonstrating the metallic coils medial to the course of the foramen transversarium. Note the massive right neck hematoma that additionally produced a large right bloody pleural effusion. C: Left vertebral arteriogram with a left subclavian injection, anteroposterior projection, showing complete obliteration of the dissecting aneurysm with preservation of the vertebral flow.

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    Case 13. A: Right vertebral arteriogram, lateral projection, demonstrating a dissecting aneurysm arising at the level of the posterior inferior cerebellar artery (PICA). B: Left vertebral arteriogram, lateral projection, showing severe vasospasm involving the distal vertebral artery. C: Left vertebral angiogram, lateral projection, obtained immediately following angioplasty revealing a return to normal caliber of the distal left vertebral artery. The deflated nondetachable angioplasty balloon is located in the proximal basilar artery. D: Right vertebral arteriogram, lateral projection, obtained 1 week after embolization with electrolytically detachable coils showing complete obliteration of the vertebral dissection with patency of the PICA.

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    Case 15. A: Left vertebral angiogram, lateral projection, demonstrating a fusiform dissecting aneurysm arising in the distal left vertebral artery. B: Right vertebral angiogram, anteroposterior projection, showing severe vasospasm (arrows) involving the distal intradural segment of the right vertebral artery. C: Right vertebral angiogram obtained immediately following angioplasty revealing marked improvement in the caliber of the spastic right vertebral artery. The angioplasty balloon and catheter were in place during this injection. D: Left vertebral angiogram, lateral projection, obtained after coil embolization of the right vertebral artery dissection demonstrating occlusion of the dissecting aneurysm with preservation of the flow to the posterior inferior cerebellar artery.

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    Case 8. A and B: Left vertebral angiograms, anteroposterior (A) and lateral (B) projections, demonstrating a dissecting aneurysm arising from the distal left vertebral artery. C: Angiogram obtained during the balloon embolization procedure showing the inflated balloon (thick arrows) outside the confines of the parent vessel. The catheter is outlined by short arrows. D: Right vertebral arteriogram obtained after embolization showing multiple platinum coils occluding the vertebral dissection. The balloon remains adjacent to the vertebral artery (arrow). E: Right vertebral angiogram demonstrating persistent severe vasospasm involving the basilar artery and posterior cerebral arteries. F: Right vertebral angiogram obtained mid-angioplasty showing the improved caliber of the basilar and right posterior cerebral artery. G: Lateral plain skull film obtained 1 year after the procedure demonstrating unchanged platinum coils within the left vertebral artery dissection site. The detachable balloon has migrated inferiorly to the C-2 level (arrow).

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