Vertebral Artery Dissecting Aneurysms Research Articles

Reconstructive treatment of symptomatic vertebral artery dissecting aneurysms with Willis covered stent: Initial experience

BackgroundSymptomatic vertebral artery dissecting aneurysm (VADA) is a challenging disease with controversy on treatment strategy due to anatomic configuration and their nature. Moreover, the outcomes of reconstructive treatment have not been well established. ObjectiveTo evaluate the safety and efficacy of reconstructive endovascular treatment (EVT) for symptomatic VADAs with Willis covered stent. MethodsWe evaluated retrospectively 13 patients with symptomatic VADAs who treated with Willis covered stent, compared with stent-assisted coiling (SAC) on the characteristics, posttreatment course, angiographic and clinical follow-up outcomes at an average of 14.4 months (range, 3–48 months). ResultsA total of 33 patients with symptomatic VADAs were reviewed, 23 of these patients with ruptured VADAs. The technical successful rate is 100% respectively in Willis covered stent (Group A) and SAC (Group B, n ​= ​20). The initial complete occlusion rate was significant higher in group A (100%) than group B (30%) (p ​< ​0.01). Major procedure-related complications were not significant different in the two groups. Serial follow-up angiograms revealed 5 recurrent VADAs in group B and no recurrence in group A (p ​> ​0.05). No obvious in-stent stenosis and no re-hemorrhage and delayed ischemic symptoms during the follow-up period. The final angiograms of all survived patients demonstrated the complete occlusion rate was higher in group A (100%) than group B (80%), but no significant statistical difference (p ​> ​0.05). Clinical outcomes were favorable in 31 (93.9%), severe disability occurred in one in group B, and only one death in group A. The final clinical outcomes were also not significant difference in the two groups (p ​> ​0.05). ConclusionsOur initial result demonstrated reconstructive EVT with Willis covered stent provides a viable approach for selected symptomatic VADAs involving the intracranial and extracranial segments, which is similar to favorable results with SAC. However, an expanded clinical experiences and larger cohort studies are needed.

Clinical Efficacy and Quality of Life Follow-Up of Reconstructive Endovascular Therapy for Acute Intracranial Vertebral Artery Dissection Aneurysms.

Background: Intracranial vertebral artery dissection aneurysms (VADAs) may cause acute ischemia or hemorrhage, in which case urgent endovascular treatment will be needed. Although the majority of patients obtain a good functional outcome after surgery, a surprising finding has been a poor quality of life (QOL) in follow-up. The purpose of this study was to evaluate clinical efficacy in reconstructive endovascular therapy for acute intracranial VADAs and to analyze the factors contributing to subsequent QOL.Methods: In this prospective study, 33 consecutive VADA patients with subarachnoid hemorrhage were recruited for comparison with 37 VADA patients with posterior circulation cerebral ischemia. All VADA patients were treated using a reconstructive strategy. Clinical, radiological, neurological, and cognitive data, as well as QOL, were assessed at admission and 6 months after surgery. Stoke Specific Quality of Life (SS-QOL) was evaluated for patients with good functional outcome [modified Ranking Scale (mRS) scoring 0-2] for subgroup analysis. Predictors for QOL at follow-up were analyzed by regression model.Results: Immediate angiography after surgery showed complete VADA obliteration in 57 (81.4%) patients and partial obliteration in 13 (18.6%) patients. Three (4.3%) cases suffered from perioperative complications, comprising two cases of stent thrombosis in the hemorrhagic group and one case of posterior inferior cerebellar artery occlusion in the ischemic group. Twenty-five (75.8%) patients in the hemorrhagic group and 30 (81.1%) patients in the ischemic group had a favorable outcome (mRS scoring 0-2) at 6-month follow-up. Follow-up angiography displayed that one case of recurrence occurred separately in both groups. Fifteen of the 33 hemorrhagic patients (45.5%) and 19 of the 37 ischemic patients (51.4%) rated QOL at follow-up as bad (SS-QOL score ≤ 3.9) despite a good functional outcome. Severity of neurological disorder and impaired neurocognition at baseline in VADA patients are proved to be independent predictors for the decline of QOL according to regression analysis.Conclusion: Reconstructive endovascular therapy for acute intracranial VADAs is a safe and effective method with a low complication rate. VADAs lead to impaired QOL at 6-month follow-up, which is attributable to multiple factors. This study demonstrated that neurological and cognitive status at baseline is of significant importance for QOL after VADAs.

A comparison of endovascular strategies in the treatment of ruptured vertebral artery aneurysms

BackgroundContemporary management of ruptured vertebral artery dissecting aneurysms (VADA) has evolved beyond proximal parent artery occlusion (PPAO) to include endovascular trapping (ET) of the diseased segment and vessel preserving stent treatments. The aim of this retrospective cohort study was to assess the outcomes of patients with ruptured VADAs who underwent endovascular management with trapping of the diseased segment as the first-line treatment approach. MethodsWe evaluated an institutional database of patients with ruptured VADAs who were treated at Auckland City Hospital from 1998 to 2017. Baseline and outcomes data were analyzed. High-grade SAH was defined as a World Federation of Neurological Surgeons or a Hunt and Hess grade of IV-V. Favorable outcome was defined as a modified Rankin Scale of 0–2. ResultsThe study cohort was comprised of 45 ruptured VADA patients with a mean age of 50 years. The mean follow-up duration was 12.9 months. ET of the diseased segment was performed in 32 cases (71.1%), PPAO of the VA was performed in 12 cases (26.7%) and reconstruction using a flow diverting stent was performed in 1 case (2.2%). The overall procedural complication rate was 13%, including procedural neurological morbidity in 4.4%. At last follow-up, no further aneurysm filling was seen in any case, and 77.8% had a favorable outcome. ConclusionET affords a favorable risk to benefit profile for patients with ruptured VADAs. ET remains a reasonable option for ruptured VADAs in patients with sufficient collateral supply to the vertebrobasilar system.

Treatment of vertebral artery dissecting aneurysms with flow diverter: A single-center experience

Objective To evaluate the safety and efficacy of flow diverter (FD) in the treatment of vertebral artery dissecting aneurysms (VADA). Methods The clinical and imaging data of perioperative period and follow-up were retrospectively collected and analyzed from 22 patients with VADA treated with FD at Department of Neurosurgery, Changhai Hospital, Navy Medical University from August 2010 to March 2019. Of the 22 aneurysms, 4 were recurrent aneurysms, 1 was acute ruptured aneurysm and 17 were unruptured aneurysms. Modified Rankin scale (mRS) was used to comprehensively evaluate the patients after surgery, and O＇kelly-Marotta (OKM) grading scale was to evaluate aneurysm embolization. Results All 24 FDs were implanted successfully in 22 VADA (with 19 Tubridge FDs and 5 Pipeline FDs). The technical success rate was 100%. Ten aneurysms were treated with FD combined with coil embolization. The immediate results of embolization were classified according to Raymond′s classification, with 2 cases of grade Ⅱ and 8 cases of grade Ⅲ. Twelve aneurysms were treated with only FD and significant intra-aneurysmal contrast hemostasis was retained immediately after operation in all 12 cases. No procedure-related hemorrhagic or ischemic complications occurred during the perioperative period. As for clinical follow-up 13.0(8.3-67.9)months, 22 patients had the mRS score of 0. No novel neurological deficits were reported. The short-term imaging follow-up at 6.0(4.7-7.1)months involved 20 cases and the complete occlusion rate was 13/20. The complete occlusion rates were 17/20 for last follow-up at 7.7(6.0-24.4) months and 8/8 for long-term follow-up at 26.5(23.3-31.4) months, respectively. No recurrence was demonstrated. Eight PICAs covered by FD and 3 PICAs harboring aneurysms were all patent during follow-up. One case developed severe in-stent stenosis at 3.5-month follow-up post FD placement in which balloon dilatation and angioplasty with stenting was performed. Twenty-two months later, the stenosis of the lumen returned to normal and the aneurysm was completely occluded. Conclusion FD treatment of VADA seems to have high surgical safety and satisfactory results. Long-term efficacy needs to be further evaluated in large case series. Key words: Intracranial aneurysm; Aneurysm, dissecting; Vertebral artery; Flow diverter

Subarachnoid hemorrhage due to de novo dissecting vertebral artery aneurysm in a patient with Guillain‐Barré syndrome

AbstractA 51‐year‐old man with Guillain‐Barré syndrome developed a dissecting vertebral artery aneurysm. Initial magnetic resonance angiography showed no abnormality, including dissecting aneurysm of the bilateral vertebral arteries. He developed subarachnoid hemorrhage. Radiological examination revealed bilateral dissecting vertebral artery aneurysms. The left ruptured dissecting vertebral artery aneurysm was treated by stent‐assisted coil embolization with preservation of the affected vertebral artery. Although it is rare, there is a possibility that dissection of the intracranial artery might occur in a patient with Guillain‐Barré syndrome in a short period of time. The dissecting aneurysm might be formed by external force to the vertebral artery, and the aneurysm might subsequently rupture due to hypertension.

Reconstructive endovascular treatment of the V4 segment of a vertebral artery dissecting aneurysm with the Willis covered stent: A retrospective study.

Preliminary studies suggest that Willis covered stents may be suitable for the treatment of aneurysms of the internal carotid artery (ICA), but their efficacy and safety in vertebral artery (VA) dissecting aneurysms need further investigation. Consecutive patients who underwent placement of a Willis covered stent for treatment of an aneurysm of the V4 segment of the VA between September 2015 and December 2017 at our institution were retrospectively reviewed. The efficacy, complications, angiographic and clinical follow-up results were collected and analyzed. Sixteen covered stents were successfully implanted into the VA in 12 patients with 12 dissecting aneurysms. The technical success rate of stenting placement was 100%. Complete occlusion was achieved in 11 patients immediately after stent placement, with transient endoleak in one aneurysm. Angiographic follow-up (9.9 ± 4.0 months, mean±SD) was performed in nine patients and demonstrated complete stabilization of the obliterated aneurysm. Clinical follow-up (20.1 ± 9.6 months, mean±SD) demonstrated full recovery in 11 patients, and one patient suffered from acute myocardial infarction. Reconstruction using a Willis covered stent is an efficient, safe and attractive alternative for the definitive treatment of intracranial VA dissecting aneurysms; longer follow-up and expanded clinical trials are needed for further validation of this technique.

Efficacy analysis of LVIS and Enterprise stent assisted coil in the treatment of vertebral artery dissection aneurysm

Objective: To observe and evaluate the therapeutic efficacy of LVIS stent and Enterprise stent assisted coil in embolization of vertebral artery dissection aneurysm (VDA). Methods: Clinical data of 96 patients with VDAs treated by LVIS stent and Enterprise stent assisted coil were analyzed retrospectively between January, 2013 and June, 2017.Of all, the LVIS stent assisted coil was performed in 28 patients (LVIS-stent group) and Enterprise in 68 patients (Enterprise-stent group). The clinical and imaging follow-up were performed. The instant embolization rate, complications, and recurrence rate were analyzed and compared between the two groups. Results: Instant angiographic results:in the LVIS stent group, complete occlusion was achieved in 17 VDAs (60.7%), near-complete occlusion in 10VDAs (35.7%), and partial occlusion in 1 VDA (3.6%). In the Enterprise stent group, complete occlusion was achieved in 27 VDAs (39.7%), near-complete occlusion in 34VDAs(50.0%), partial occlusion in 7VDAs (10.3%). Procedure-related complications occurred in 3 patients (10.7%) in LVIS stent group and 3 patients (4.4%) in Enterprise stent group. DSA follow-up was performed during 6 to 12 months after surgery, and 10 patients with vertebral artery dissection aneurysm recurred, 2 in the LVIS group and 8 in the Enterprise stent group. The latest modified Rankin Scale score was 0 in 55 patients,1 in 13, 2 in 1, 3 in 1, and 6 in 1. Among them, all follow-up patients in the LVIS stent group had good prognosis, while in the Enterprise stent group, 50 patients (94.4%) had a good prognosis. Conclusions: The stent-assisted coils have a higher degree of embolization in the vertebral artery dissection aneurysms, a higher rate of near-total embolization, a lower incidence of neurological complications, and a good prognosis. The complete andnear-complete occlusion rates and the incidence of neurological complicationsin the LVIS group was higher than that in the Enterprise groupand the recurrence ratesin the LVIS group was lower than that in the Enterprise group,both with no statistically significant difference.

Endovascular Therapy for Ruptured Vertebral Artery Dissecting Aneurysms: Results from Nationwide, Retrospective, Multi-Center Registries in Japan (JR-NET3).

Ruptured vertebral artery dissecting aneurysm (VADA) causes subarachnoid hemorrhage (SAH), and parent artery occlusion (PAO) with endovascular technique (EVT) has been the first-line treatment for ruptured VADA. In this study, we have extracted 530 ruptured VADA, treated through PAO with EVT, from a nationwide, retrospective, multi-center registration in Japan (JR-NET3), and analyzed factors associated with outcome at 30 days and procedure-related complications. Complete occlusion was achieved in 497 cases (93.8%) and favorable outcome was obtained in 303 cases (59.1%). Older age (≥60 years), male sex, use of general anesthesia, non-specialist as the responsible doctor, and time delay from onset to treatment (≥24 h) were negative factors for favorable outcome in multivariate analysis, although these factors were not associated with procedure-related complications. Compared with previous studies (JR-NET1 and 2), the number of endovascular treatments for patients with VADA and severe SAH increased in this decade; however, the percentage of patients with favorable outcome did not decrease. This might be due to not only the improvement of endovascular treatment itself, but also increased access to endovascular specialists or standardization of management.

Effects of Posterior Fossa Decompression in Patients with Hunt and Hess Grade 5 Subarachnoid Hemorrhage After Endovascular Trapping of Ruptured Vertebral Artery Dissecting Aneurysms

A ruptured vertebral artery dissecting aneurysm (VADA) with a high clinical grade (Hunt and Hess grade 5) has a devastating prognosis. Because of the high rebleeding rate and location, rapid mortality can occur in patients owing to brainstem compression. Adjuvant decompression of the posterior fossa after securing the aneurysm may improve the outcomes of these patients. Between January 2011 and December 2016, 22 patients who presented with Hunt and Hess grade 5 ruptured VADA underwent endovascular treatment. Patients were divided into 2 groups: group 1 (n= 12) received conventional endovascular treatment of VADA and external ventricular drainage, and group 2 (n= 10) received external ventricular drainage and suboccipital craniectomy for posterior fossa decompression after rapid endovascular trapping of VADA. In group 2, the survival rate and good clinical outcome rate (modified Rankin scale score ≤2) were 80% and 60%, respectively, which were favorable to the corresponding rates in group 1 (66.67% and 16.67%). Moreover, 80% of patients (8/10) in group 2 regained consciousness compared with 50% of patients in group1. Adjuvant decompression of the posterior fossa can improve outcomes in patients with Hunt and Hess grade V ruptured VADA.

Ruptured Vertebral Artery Dissecting Aneurysm as a Risk Factor for Ocular Symptoms Accompanied with Subarachnoid Hemorrhage

Although ruptured vertebral artery dissecting aneurysms (VADAs) are often associated with ocular symptoms, such as abducent nerve palsy and Terson syndrome (TS), their frequency and risk factors in comparison with those associated with ruptured aneurysms in other locations have not been reported. Three hundred forty-three patients with nontraumatic subarachnoid hemorrhage were treated in our hospital from April 2002 to May 2016, among which 35 (10.2%) had VADA as the origin of hemorrhage. They were analyzed retrospectively for risk factors of ocular symptoms. Of the 343 patients, 26 had eye movement disturbance (7.6%) and 22 had TS (6.4%). Both eye movement disturbance (14 patients; 40.0%; P < 0.0001) and TS (10 patients; 28.6%; P < 0.0001) occurred more frequently in the VADA than the non-VADA group. Abducent nerve palsy accounted for all eye movement disturbances associated with ruptured VADA, although it occurred in 6 of 12 affected patients with ruptured aneurysms in other locations. Of these patients, 4 improved within 3 months (28.6%) and 8 did so within 1 year (66.7%). Multivariate logistic regression analysis indicated that ruptured VADA is a risk factor for both eye movement disturbance and TS (P < 0.0001 and P=0.0033; 95% confidence interval of odds ratio: 3.41-29.5 and 1.72-14.33, respectively). Eye movement disturbance and TS occurs more frequently in patients with ruptured VADA than with aneurysms in other locations. Early evaluation by an ophthalmologist is recommended in these patients.

Rare case of diffuse spinal arachnoiditis following a complicated vertebral artery dissection

Spinal arachnoiditis (SA) is an extremely rare and delayed complication of subarachnoid hemorrhage (SAH). Little is known about its underlying pathogenesis and subsequent clinical course. A middle-aged patient presented with the worst headache of her life and a grade 3 SAH of the basal-cisterns and posterior fossa was identified on Computed Tomography scans (CT). Angiography revealed a ruptured dissecting aneurysm of the left vertebral artery (VA-V4), as well as an unruptured left Anterior Cerebral Artery (ACA-A1) aneurysm. The VA aneurysm was treated with flow diversion. The patient re-ruptured the stented aneurysm, another telescoping pipeline was placed. The patient developed polymicrobial ventriculitis, and returned several months later complaining of paraparesis and left sided weakness. Magnetic Resonance Imaging (MRI) revealed diffuse thecal dural thickening from the cervicomedullary junction to the sacrum. Loculations, diffuse edema and cord compression were noticed along the inferior surface of the cerebellum, and the cervico-thoracic spine with a T4–T6 syrinx. The patient underwent a posterior (T4–T8) spinal fusion and (T5–T7) decompression with arachnoid-cyst fenestration and placement of a subarachnoid-pleural shunt. On latest follow-up, the patient is weaning off the thoraco-lumbosacral orthosis and ambulating with a cane. SA is often a complicated two-staged disease in which a “free interval phase” separates the initial inflammatory reaction (IIR) from the late adhesive phase. Posterior fossa bleeding, warranting prolonged surveillance, additional bleeding and ventriculitis might augment the risk and the severity of arachnoiditis.

One-stage Stent-assisted Coil Embolization for Rupture-side-unknown Bilateral Vertebral Artery Dissecting Aneurysms in an Acute Stage: A Case Report

Bilateral vertebral artery dissecting aneurysms (VADAs) with subarachnoid hemorrhage (SAH) are rare and their management is still challenging. In this report, we successfully performed one-stage stent-assisted coil embolization (SAC) for bilateral VADAs with SAH in an acute stage, because the ruptured side could not be diagnosed. A 47-year-old woman presented with a sudden onset of headache without laterality, and left-side dominant SAH with bilateral VADAs was noted on computed tomography (CT) scans. The size of aneurysmal dome and neck was similar between the two VADAs, and a bleb was observed only on the right VADA. In computational fluid dynamics (CFD) simulations, findings of wall shear stress (WSS), normalized WSS, and WSS gradient suggested that the left VADA was ruptured, while the oscillatory shear index and aneurysm formation indicator suggested the opposite-side one to be ruptured. Thus, we could not determine which VADA was ruptured by clinical data and CFD analyses. Therefore, we performed simultaneous treatment for the bilateral VADAs by using SAC technique 8 h after the onset under dual antiplatelet and anticoagulation therapies. There was no evidence of rebleeding and stent thrombosis. Stent thrombosis was monitored by duplex color-coded ultrasonography after the intervention. She was discharged without neurological deficits, and 6-month follow-up cerebral angiography demonstrated no recanalization of VADAs. This is the first report showing bilateral VADAs with SAH treated by one-stage SAC within 24 h of SAH, and the potential risks are discussed.

Unruptured Vertebral Artery Dissecting Aneurysms: Approach Strategy by Retrospective Analysis

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.

Predictive factors of medullary infarction after endovascular internal trapping using coils for vertebral artery dissecting aneurysms.

OBJECTIVE The first choice of treatment in cases of vertebral artery dissecting aneurysms (VADAs) is endovascular internal trapping (EIT) of the dissecting segment using coils. However, this procedure carries the risk of medullary infarction, and the risk factors for this complication are not well understood. This study investigated the risk factors causing medullary infarction. METHODS One hundred patients who underwent EIT for VADAs were included in this study. Ninety-three patients presented with subarachnoid hemorrhage. In cases involving the posterior inferior cerebellar artery (PICA), partial internal trapping targeting the ruptured site was performed to preserve the PICA. The VADAs were classified into the distal VA stump group, proximal VA stump group, and entire VA stump group, according to the location of VA segments without adequate flow-out vessels (such as the PICA [VA stump]) at risk of delayed thrombosis. The occurrence of medullary infarction was examined in each group using diffusion-weighted MRI and/or clinical symptoms. Various measurements were performed on digital subtraction angiography, and the risk factors for medullary infarction were analyzed. RESULTS Medullary infarction occurred in 30 patients, affecting the posterolateral medulla in 27 patients and the anteromedial medulla in 3 patients. Medullary infarction occurred in 3 of 47 patients (6%) in the distal VA stump group, 10 of 19 patients (53%) in the proximal VA stump group, and 17 of 34 patients (50%) in the entire VA stump group. The length of trapping was significantly longer in the infarction group than in the noninfarction group but did not differ among the 3 groups. Total length (length of trapping plus VA stump) was a risk factor for medullary infarction in the proximal VA stumps. CONCLUSIONS The primary risk factor for medullary infarction after EIT is not the length of trapping; rather, it is the anatomical location of the VADAs. The risk of medullary infarction is low in cases with distal VA stumps, but the symptoms are severe. Preservation of the origin of the anterior spinal artery can reduce the risk of medullary infarction. The risk of medullary infarction is high in cases with proximal VA stumps, but the symptoms are mild. A shorter length of trapping, although less likely to lead to complications, cannot prevent medullary infarction because the total length depends on the anatomical location of the PICA and not on the surgical technique. Reconstructive therapy should be indicated for patients with ruptured VADAs at high risk of severe ischemic complications (e.g., patients with hypoplasia of the contralateral VA or cases involving the PICA or anterior spinal artery, which are inappropriate for partial internal trapping) or for patients with unruptured VADAs.

Reconstructive endovascular treatment of vertebral artery dissecting aneurysms with the Low-profile Visualized Intraluminal Support (LVIS) device.

IntroductionThe Low-profile Visualized Intraluminal Support (LVIS) device is a new generation of self-expanding braided stent recently introduced in China for stent assisted coiling of intracranial aneurysms. The aim of our study is to evaluate the feasibility, safety, and efficacy of the LVIS device in reconstructive treatment of vertebral artery dissecting aneurysms (VADAs).MethodsWe retrospectively reviewed the neurointerventional database of our institution from June 2014 to May 2016. Patients who underwent endovascular treatment of VADAs with LVIS stents were included in this study. Clinical presentation, aneurysmal characteristics, technical feasibility, procedural complications, and angiographic and clinical follow-up results were evaluated.Results38 patients with VADAs who underwent treatment with LVIS stent were identified, including 3 ruptured VADAs. All VADAs were successfully treated with reconstructive techniques including the stent-assisted coiling (n = 34) and stenting only (n = 4). Post-procedural complications developed in 3 patients (7.9%) including two small brainstem infarctions and one delayed thromboembolic event. Complications resulted in one case of minor permanent morbidity (2.6%). There was no procedure-related mortality. The follow-up angiogram was available in 30 patients at an average of 8.3 months (range, 2 to 30 months), which revealed complete occlusion in 23 patients (76.7%), residual neck in five patients (16.7%), and residual sac in two patients (6.7%). The follow-up of 25 aneurysms with incomplete immediate occlusion revealed 22 aneurysms (88%) with improvement in the Raymond class. One aneurysm (3.3%) showed recanalization and required retreatment. Clinical followed-up at 5–28 months (mean 14.1 months) was achieved in 36 patients because two patients died of pancreatic cancer and basal ganglia hemorrhage, respectively. No new neurologic deterioration or aneurysm (re)bleeding was observed.ConclusionsOur preliminary experience with reconstruction of VADAs with the LVIS device demonstrates that this treatment approach is feasible with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies are necessary to determine long-term outcomes of this therapy.

Endovascular coil oclusion of spontaneous ruptured vertebral artery dissecting aneurysm

Abstract Spontaneous dissecting aneurysm of vertebral artery is known as a rare pathological condition causing a subarachnoid hemorrhage in the posterior circulation. The treatment of ruptured vertebral artery dissecting aneurysms is still an important subject of debates in the literature. We present a particular case of ruptured vertebral artery dissecting aneurysms that was treated by only endovascular Guglielmi detachable coils occlusion. A brief review of technical possibilities of treatment of these types of vascular lesions, with their advantages and disadvantages are discussed.

Successful Retreatment of Recurrent Intracranial Vertebral Artery Dissecting Aneurysms After Stent-Assisted Coil Embolization: A Self-Controlled Hemodynamic Analysis

Intracranial vertebral artery dissecting aneurysms (VADAs) tend to recur despite successful stent-assisted coil embolization (SACE). Hemodynamics is useful in evaluating aneurysmal formation, growth, and rupture. Our aim was to evaluate the hemodynamic patterns of the recurrence of VADA. Between September 2009 and November 2013, all consecutive patients with recurrent VADAs afterSACE in our institutions were enrolled. Recurrence was defined as recanalization and/or regrowth. We assessed the hemodynamic alterations in wall shear stress(WSS) and velocity after the initial SACE and subsequently after retreatment of the aneurysms that recurred. Five patients were included. After the initial treatment, 3 patients showed recanalization and 2 showed regrowth. In the 2 patients with regrowth, the 2 original aneurysms maintained complete occlusion; however, denovo aneurysm regrowth was confirmed near the previous site. Compared with 3 recanalized aneurysms, the completely occluded aneurysms showed high mean reductions in velocity and WSS after initial treatment (velocity, 77.6% vs. 57.7%; WSS, 74.2% vs. 52.4%); however, WSS remained high at the region near the previous lesion where the new aneurysm originated. After the second retreatment, there was no recurrence in any patient. Compared with the 3 aneurysms that recanalized, the 4aneurysms that maintained complete occlusion showed higher reductions in velocity (62.9%) and WSS (71.1%). Our series indicated that hemodynamics might have an important role in recurrence of VADAs. After endovascular treatment, sufficient hemodynamic reduction in aneurysm dome, orifice, and parent vessel may be one of the key factors for preventing recurrence in VADAs.

Endovascular Treatment of Ruptured Vertebral Artery Dissecting Aneurysms

Background: Various endovascular treatment methods have been used to treat ruptured vertebral artery dissecting aneurysms (VADAs). However, the efficacy and long-term durability of the various endovascular techniques have remained unestablished. Objectives: The purpose of the present study is to report the therapeutic efficacy and long-term clinical and angiographic results of various endovascular treatment methods, and to evaluate the predictive factors of favorable outcomes. Patients and Methods: Between January 2010 and August 2014, 30 patients with ruptured VADAs were classified according to the dominancy of the affected vertebral artery (VA) and the involved major perforating vessels. Allotted endovascular therapy was performed for each of the ruptured VADA subtypes. Immediate angiographic and follow-up imaging results were retrospectively reviewed, and long-term clinical results were evaluated. Various clinical, angiographic, and procedural factors were evaluated to determine their associations with clinical outcomes. Results: Dissecting aneurysms involving the dominant VA were found in five patients. Of 25 aneurysms involving the non-dominant VA, 12 lesions showed involvement of the posterior inferior cerebellar artery (PICA), and one lesion’s origin was the anterior spinal artery. Stent-assisted coiling (SAC) was performed in seven patients, stent-only therapy (SOT) was conducted for six patients, and the remaining 17 patients were treated with internal coil trapping (ICT). Of the seven patients treated with SAC, five showed partial obliteration and four experienced recurrence. Two of the four patients with recurrence died. One patient with incomplete trapping for patency of the involved PICA experienced rebleeding. No recurrence was observed in six patients treated with SOT, or among 16 patients with ICT. The preoperative neurologic status (represented by the world federation of neurosurgical societies grading) and immediate post-treatment angiographic results were confirmed as significant predictive factors of clinical outcomes (P =0.018 for both variables). Conclusion: Incomplete obliteration of a ruptured VADA using SAC was associated with a higher recurrence rate and fatal clinical outcomes. ICT is a useful technique that completely eliminates the risk of rebleeding. However, under a limited set of conditions, SOT can be an effective alternative.

A Ruptured Vertebral Artery Dissecting Aneurysm Involving the Anterior Spinal Artery:A Case Report

A 50-year-old woman presented with a subarachnoid hemorrhage caused by a ruptured vertebral artery dissecting aneurysm(VADA)involving the anterior spinal artery(ASA). The ASA branched at the proximal component of the dissecting aneurysm. The rupture point was presumed to be the distal region of the dissecting aneurysm. We performed coil embolization of the distal part only in order to prevent rebleeding and preserve the ASA. The patient showed no neurological deficits. Six months after the procedure, an angiogram demonstrated occlusion of a distal portion of the right vertebral artery. However, the ASA was still patent. No rebleeding occurred, and the patient has remained neurologically symptom-free for 3 years from the treatment. ASA-involved VADAs are extremely rare. Treatment strategy is difficult because there are no options for bypass surgery and occlusion of the ASA may lead to quadriplegia unless there is collateral flow to the ASA. Although the outcome of the patient was good with partial coil embolization in this case, the treatment strategy should be carefully considered for ASA-involved VADAs.

Only overlapping stents therapy for intracranial vertebral artery dissection aneurysms

To evaluate the feasibility, safety, clinical, and angiographic follow-up of only overlapping stents therapy for intracranial vertebral artery dissection aneurysms (VADA). Eight consecutive patients (6 men, 2 women; mean age 46.8 years ranging from 34 to 62 years) with intracranial VADA admitted to Department of Neurology, Chinese People's Liberation Army General Hospital from June 2008 to June 2014 were retrospectively reviewed. All patients were diagnosed intracranial VADA by MRI or digital subtraction angiography (DSA). All patients were treated by only overlapping stents therapy under general anesthesia. In the endovascular treatment process 2 to 3 Solitaire, Neuroform or Wingspan self-expandable stents were overlapping implanted in the segment of the aneurysms. All patients received routine antiplatelet therapy before and after endovascular treatment. The operative procedures were succeeded in all patients. Eight patients were implanted 18 stents (2 patients, 3 stents; 6 patients, 2 stents). The stents were located accurately and implanted smoothly, none perioperative complications occurred. All patients lived and worked normally and had no recurrent symptoms on follow-up of 6 to 48 months. All patients performed DSA reexamination on follow-up. The aneurysm blocked in 2 patients, the size lessened in 2 patients, and the size had no change in 3 patients. Only overlapping stents therapy for treating intracranial VADA is feasible and has good operation safety. Preliminary follow-up results show that it can reduce the probability of thrombosis or hemorrhage and can improve the patients' life quality.