Dissecting aneurysms of the vertebral artery: a management strategy

View More View Less
  • 1 Department of Cerebrovascular Surgery, National Cardiovascular Center, Osaka, Japan
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object. The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA).

Methods. Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)—PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA—PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%.

Conclusions. Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address reprint requests to: Koji Iihara, M.D., Department of Cerebrovascular Surgery, National Cardiovascular Center, 5–7–1, Fujishiro-dai, Suita, Osaka, 565–8565, Japan. email: kiihara@hsp.ncvc.go.jp.
  • 1.

    Aoki N, & Sakai T: Rebleeding from intracranial dissecting aneurysm in the vertebral artery. Stroke 21:16281631, 1990 Aoki N, Sakai T: Rebleeding from intracranial dissecting aneurysm in the vertebral artery. Stroke 21:1628–1631, 1990

    • Search Google Scholar
    • Export Citation
  • 2.

    Berger MS, & Wilson CB: Intracranial dissecting aneurysms of the posterior circulation. Report of six cases and review of the literature. J Neurosurg 61:882894, 1984 Berger 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.

    Bogousslavsky J, , Gates PC, & Fox AJ, et al: Bilateral occlusion of vertebral artery: clinical patterns and long-term prognosis. Neurology 36:13091315, 1986 Bogousslavsky J, Gates PC, Fox AJ, et al: Bilateral occlusion of vertebral artery: clinical patterns and long-term prognosis. Neurology 36:1309–1315, 1986

    • Search Google Scholar
    • Export Citation
  • 4.

    Durward QJ: Treatment of vertebral artery dissecting aneurysm by aneurysm trapping and posterior inferior cerebellar artery reimplantation. Case report. J Neurosurg 82:137139, 1995 Durward QJ: Treatment of vertebral artery dissecting aneurysm by aneurysm trapping and posterior inferior cerebellar artery reimplantation. Case report. J Neurosurg 82:137–139, 1995

    • Search Google Scholar
    • Export Citation
  • 5.

    Friedman AH, & Drake CG: Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60:325334, 1984 Friedman AH, Drake CG: Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60:325–334, 1984

    • Search Google Scholar
    • Export Citation
  • 6.

    Graves VB, , Perl J II, & Strother CM, et al: Endovascular occlusion of the carotid or vertebral artery with temporary proximal flow arrest and microcoils: clinical results. AJNR 18:12011206, 1997 Graves VB, Perl J II, Strother CM, et al: Endovascular occlusion of the carotid or vertebral artery with temporary proximal flow arrest and microcoils: clinical results. AJNR 18:1201–1206, 1997

    • Search Google Scholar
    • Export Citation
  • 7.

    Gurian JH, , Vinuela F, & Gobin YP, et al: Aneurysm rupture after parent vessel sacrifice: treatment with Guglielmi detachable coil embolization via retrograde catheterization: case report. Neurosurgery 37:12161221, 1995 Gurian JH, Vinuela F, Gobin YP, et al: Aneurysm rupture after parent vessel sacrifice: treatment with Guglielmi detachable coil embolization via retrograde catheterization: case report. Neurosurgery 37:1216–1221, 1995

    • Search Google Scholar
    • Export Citation
  • 8.

    Halbach VV, , Higashida RT, & Dowd CF, et al: Endovascular treatment of vertebral artery dissections and pseudoaneurysms. J Neurosurg 79:183191, 1993 Halbach 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
  • 9.

    Hopkins LN, , Martin NA, & Hadley MN, et al: Vertebrobasilar insufficiency. Part 2. Microsurgical treatment of intracranial vertebrobasilar disease. J Neurosurg 66:662674, 1987 Hopkins LN, Martin NA, Hadley MN, et al: Vertebrobasilar insufficiency. Part 2. Microsurgical treatment of intracranial vertebrobasilar disease. J Neurosurg 66:662–674, 1987

    • Search Google Scholar
    • Export Citation
  • 10.

    Kamiyama H, , Nomura M, & Abe H, et al: Diagnosis for the intracranial dissecting aneurysms. Surg Cereb Stroke 18:5056, 1990 Kamiyama H, Nomura M, Abe H, et al: Diagnosis for the intracranial dissecting aneurysms. Surg Cereb Stroke 18:50–56, 1990

    • Search Google Scholar
    • Export Citation
  • 11.

    Kitanaka C, , Morimoto T, & Sasaki T, et al: Rebleeding from vertebral artery dissection after proximal clipping. Case report. J Neurosurg 77:466468, 1992 Kitanaka 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
  • 12.

    Kitanaka C, , Sasaki T, & Eguchi T, et al: Intracranial vertebral artery dissections: clinical, radiological features, and surgical considerations. Neurosurgery 34:620627, 1994 Kitanaka C, Sasaki T, Eguchi T, et al: Intracranial vertebral artery dissections: clinical, radiological features, and surgical considerations. Neurosurgery 34:620–627, 1994

    • Search Google Scholar
    • Export Citation
  • 13.

    Kitanaka C, , Tanaka J, & Kuwahara M, et al: Nonsurgical treatment of unruptured intracranial vertebral artery dissection with serial follow-up angiography. J Neurosurg 80:667674, 1994 Kitanaka C, Tanaka J, Kuwahara M, et al: Nonsurgical treatment of unruptured intracranial vertebral artery dissection with serial follow-up angiography. J Neurosurg 80:667–674, 1994

    • Search Google Scholar
    • Export Citation
  • 14.

    Kurata A, , Ohmomo T, & Miyasaka Y, et al: Coil embolization for the treatment of ruptured dissecting vertebral aneurysms. AJNR 22:1118, 2001 Kurata 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
  • 15.

    Lister JR, , Rhoton AL Jr, & Matsushima T, et al: Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10:170199, 1982 Lister JR, Rhoton AL Jr, Matsushima T, et al: Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10:170–199, 1982

    • Search Google Scholar
    • Export Citation
  • 16.

    Mahmood A, , Dujovny M, & Torche M, et al: Microvascular anatomy of foramen caecum medullae oblongatae. J Neurosurg 75:299304, 1991 Mahmood 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
  • 17.

    Manabe H, , Hatayama T, & Hasegawa S, et al: Coil embolization for ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery. Neuroradiology 42:384387, 2000 Manabe H, Hatayama T, Hasegawa S, et al: Coil embolization for ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery. Neuroradiology 42:384–387, 2000

    • Search Google Scholar
    • Export Citation
  • 18.

    Manabe H, , Ohkuma H, & Fujita S, et al: Coil embolization of ruptured vertebral dissection in acute stage with interlocking detachable coils. Surg Neurol 47:476480, 1997 Manabe H, Ohkuma H, Fujita S, et al: Coil embolization of ruptured vertebral dissection in acute stage with interlocking detachable coils. Surg Neurol 47:476–480, 1997

    • Search Google Scholar
    • Export Citation
  • 19.

    Mizutani T, , Aruga T, & Kirino T, et al: Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 36:905913, 1995 Mizutani 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
  • 20.

    Mizutani T, & Miki Y: Surgical considerations for PICA-involved type vertebral dissecting aneurysm. Surg Cereb Stroke 27:369374, 1999 Mizutani T, Miki Y: Surgical considerations for PICA-involved type vertebral dissecting aneurysm. Surg Cereb Stroke 27:369–374, 1999

    • Search Google Scholar
    • Export Citation
  • 21.

    Mokri B, , Houser OW, & Sandok BA, et al: Spontaneous dissections of the vertebral arteries. Neurology 38:880885, 1988 Mokri B, Houser OW, Sandok BA, et al: Spontaneous dissections of the vertebral arteries. Neurology 38:880–885, 1988

    • Search Google Scholar
    • Export Citation
  • 22.

    Nakagawa K, , Touho H, & Morisako T, et al: Long-term follow-up study of unruptured vertebral artery dissection: clinical outcomes and serial angiographic findings. J Neurosurg 93:1925, 2000 Nakagawa K, Touho H, Morisako T, et al: Long-term follow-up study of unruptured vertebral artery dissection: clinical outcomes and serial angiographic findings. J Neurosurg 93:19–25, 2000

    • Search Google Scholar
    • Export Citation
  • 23.

    Senter HJ, & Sarwar M: Nontraumatic dissecting aneurysm of the vertebral artery. Case report. J Neurosurg 56:128130, 1982 Senter HJ, Sarwar M: Nontraumatic dissecting aneurysm of the vertebral artery. Case report. J Neurosurg 56:128–130, 1982

    • Search Google Scholar
    • Export Citation
  • 24.

    Steinberg GK, , Drake CG, & Peerless SJ: Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients. J Neurosurg 79:161173, 1993 Steinberg GK, Drake CG, Peerless SJ: Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients. J Neurosurg 79:161–173, 1993

    • Search Google Scholar
    • Export Citation
  • 25.

    Su CC, , Watanabe T, & Yoshimoto T, et al: Proximal clipping of dissecting intracranial vertebral aneurysm—effect of balloon Matas test with neurophysiological monitoring. Case report. Acta Neurochir 104:5963, 1990 Su CC, Watanabe T, Yoshimoto T, et al: Proximal clipping of dissecting intracranial vertebral aneurysm—effect of balloon Matas test with neurophysiological monitoring. Case report. Acta Neurochir 104:59–63, 1990

    • Search Google Scholar
    • Export Citation
  • 26.

    Sundt TM Jr, & Piepgras DG: Occipital to posterior inferior cerebellar artery bypass surgery. J Neurosurg 48:916928, 1978 Sundt TM Jr, Piepgras DG: Occipital to posterior inferior cerebellar artery bypass surgery. J Neurosurg 48:916–928, 1978

    • Search Google Scholar
    • Export Citation
  • 27.

    Takikawa S, , Kamiyama H, & Nomura M, et al: [Vertebral dissecting aneurysm treated with trapping and bilateral posterior inferior cerebellar artery side-to side anastomosis; case report.] No Shinkei Geka 19:571576, 1991 (Jpn) Takikawa S, Kamiyama H, Nomura M, et al: [Vertebral dissecting aneurysm treated with trapping and bilateral posterior inferior cerebellar artery side-to side anastomosis; case report.] No Shinkei Geka 19:571–576, 1991 (Jpn)

    • Search Google Scholar
    • Export Citation
  • 28.

    Yamada K, , Hayakawa T, & Ushio Y, et al: Therapeutic occlusion of the vertebral artery for unclippable vertebral aneurysm: relationship between site of occlusion and clinical outcome. Neurosurgery 15:834838, 1984 Yamada K, Hayakawa T, Ushio Y, et al: Therapeutic occlusion of the vertebral artery for unclippable vertebral aneurysm: relationship between site of occlusion and clinical outcome. Neurosurgery 15:834–838, 1984

    • Search Google Scholar
    • Export Citation
  • 29.

    Yamada M, , Miyasaka K, & Kurata A, et al: Problems in the treatment of intracranial dissecting vertebral aneurysms. Surg Cereb Stroke 22:4146, 1994 Yamada M, Miyasaka K, Kurata A, et al: Problems in the treatment of intracranial dissecting vertebral aneurysms. Surg Cereb Stroke 22:41–46, 1994

    • Search Google Scholar
    • Export Citation
  • 30.

    Yamaura A, , Watanabe Y, & Saeki N: Dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 72:183188, 1990 Yamaura A, Watanabe Y, Saeki N: Dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 72:183–188, 1990

    • Search Google Scholar
    • Export Citation
  • 31.

    Yamaura A, , Yoshimoto T, & Hashimoto N, et al: Nationwide study of nontraumatic intracranial arterial dissection: clinical features and outcome. Surg Cereb Stroke 26:7986, 1998 Yamaura A, Yoshimoto T, Hashimoto N, et al: Nationwide study of nontraumatic intracranial arterial dissection: clinical features and outcome. Surg Cereb Stroke 26:79–86, 1998

    • Search Google Scholar
    • Export Citation
  • 32.

    Yamaura 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 90:853856, 1999 Yamaura 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
  • 33.

    Yasui T, , Komiyama M, & Nishikawa M, et al: Subarachnoid hemorrhage from vertebral artery dissecting aneurysms involving the origin of the posteroinferior cerebellar artery: report of two cases and review of the literature. Neurosurgery 46:196201, 2000 Yasui T, Komiyama M, Nishikawa M, et al: Subarachnoid hemorrhage from vertebral artery dissecting aneurysms involving the origin of the posteroinferior cerebellar artery: report of two cases and review of the literature. Neurosurgery 46:196–201, 2000

    • Search Google Scholar
    • Export Citation
  • 34.

    Yonas H, , Agamanolis D, & Takaoka Y, et al: Dissecting intracranial aneurysms. Surg Neurol 8:407415, 1977 Yonas H, Agamanolis D, Takaoka Y, et al: Dissecting intracranial aneurysms. Surg Neurol 8:407–415, 1977

    • Search Google Scholar
    • Export Citation
  • 35.

    Yoshimoto Y, & Wakai S: Unruptured intracranial vertebral artery dissection. Clinical course and serial radiographic imagings. Stroke 28:370374, 1997 Yoshimoto Y, Wakai S: Unruptured intracranial vertebral artery dissection. Clinical course and serial radiographic imagings. Stroke 28:370–374, 1997

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 847 350 45
Full Text Views 356 45 2
PDF Downloads 202 22 0
EPUB Downloads 0 0 0