Unruptured Vertebral Artery Dissecting Aneurysms: Approach Strategy by Retrospective Analysis

Arash Dooghaie Moghadam,Yasaman Arjmand,Ali Keipourfard

doi:10.12691/ajmcr-5-8-2

Abstract

Objectives: The natural course of un-ruptured vertebral artery dissecting aneurysms (VADAs) is not completely clear. We aim to retrospectively develop a strategy for treating un-ruptured VADAs based on long-term follow-up. Methods: We retrospectively studied 35 patients with un-ruptured VADAs. The initial symptom of 20 patients was headache, followed by ischemic symptoms and mass effect in 11 and 4 patients respectively. All of the patients underwent Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) at the time of admission and 2 weeks and 1, 4, 6, 12, and 24 months after initial presentation. Asymptomatic patients with enlarging dissection site defined on MRI and MRA, received further treatment and work up. Results: Two patients received emergency intervention due to symptom exacerbation and unstable status. The other 33 patients underwent conservative management. Lesion enlargement was observed in 2 cases during imaging follow up. In follow up period, additional interventions including dissection trap by surgery and coil embolization were conducted in 1 and 3 patients respectively. Other 31 patients remain symptom free and were managed conservatively. Dissection site remained unchanged in majority of patients (68.57%), improved in 28.57% and disappeared in 2.85% of the patients. Ten patients with recurrent ischemic attacks underwent anti-platelet therapy, without any bleeding complaint or permanent neurological deficits. Conclusion: The nature of an un-ruptured VADA is not highly aggressive. However, enlarged dissection site without new manifestations, occlusion is recommended. Also, anti-platelet therapy is suggested in patients with recurrent ischemic attacks.

Highlights

Trapping with Guglielmi detachable coils (Boston Scientifics, Natick, MA, USA) using double micro-catheter technique was performed in vertebral artery dissecting aneurysms (VADAs) which did not involve posterior inferior cerebellar artery (PICA)
Proximal occlusion of VA by Guglielmi detachable coil was performed in one patient, while the other one underwent direct dissection site trap by open surgery due to PICA involvement
Twenty four (68.57%) patients showed no further changes on Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) studies

Summary

Introduction

Since there is no unified and acceptable follow-up and treatment have not been defined, we plan to investigate the natural history and of un-ruptured vertebral artery dissecting aneurysms (VADAs). Between October 2011 and March 2016, 20 male and 15 female patients (N=35) with un-ruptured VADAs with signed informed patient consent form were admitted to Shohada Tajrish Hospital. All of the patients were studied by MRI and MRA, by focusing on series of diagnostic criteria, such as stenotic segments as string sign, occluded segments, pseudo-aneurysm and irregularity of lumen. Asymptomatic patients with enlarging dissection site on MRI and MRA and patients with progressive focal neurological symptoms despite anti-platelet therapy underwent angiography, by a 6French guiding catheter and a non-detachable balloon as a test for occlusion in affected VADA. This study was conducted under the principles of the Helsinki Declaration and approved by the Ethics Committee of Shohada Tajrish hospital

Objectives

Results

Conclusion