Vertebral Artery Dissecting Aneurysms Research Articles

Hemifacial spasm and jugular foramen syndrome caused by diametrically opposite aneurysms on the vertebral artery

Vertebral artery (VA) aneurysms commonly occur on a fusiform segment of the artery and have unusual appearances and characteristics [1]. They commonly present with symptoms of cranial nerve compression secondary to related dolichoectasia, mass effect or subarachnoid hemorrhage. In the setting of a VA aneurysm, hemifacial spasm occurs when the VA is ectatic or fusiform, while individual lower cranial nerve palsies have been reported in saccular and fusiform cases [1]. A simultaneous occurrence of these two clinical syndromes related to an aneurysmal VA has not been described. A 50-year-old lady presented with left-sided hemifacial spasm of 2-year duration and nasal regurgitation and altered phonation of 1-year duration. Both the symptoms were insidious in onset and were progressive. There was no history of facial pain or numbness, tinnitus or vertigo. Her neurological deficits included left sided IX, X nerve palsies. Examination of the other cranial nerves was normal. MRI of the brain showed a mildly ectatic vertebro-basilar artery (VBA) on the left side with compression on the VII–VIII nerve complex (Fig. 1a). Digital subtraction angiogram (DSA) revealed an ectatic left VA with a ventrolaterally pointing, distal 12 9 8 9 6 mm sized saccular aneurysm and a small blister aneurysm (3 9 3 mm) directed dorsomedially (Fig. 1b, c). At surgery via a far lateral craniectomy, the saccular aneurysm directed toward the jugular foramen was found arising proximal to origin of the posterior inferior cerebellar artery (PICA) which was draped on the aneurysm (Fig. 2a). It was clipped with a 10-mm angled ring clip, with the ring enclosing the VA (Fig. 2b). The clipped aneurysm was then opened and decompressed. The dorsally directed blister aneurysm compressing the facial nerve at its exit from the pons (Fig. 2b) was wrapped with muscle and dura. Teflon was interposed between the nerve and the ectatic VA segment. The risk of rupturing the nearby blister aneurysm and narrowing the ectatic VA precluded reconstruction of the VA with clips. Postoperatively, the patient was relieved of her hemifacial spasm, while her lower cranial nerve palsy remained status quo. An aneurysmal etiology is noted in 0.3–0.6 % of all cases of hemifacial spasm. The postulated pathogenesis is related to the compression of the root entry zone (REZ) of the facial nerve by the pulsations of the aneurysm. In 7.5–21 % of the cases an ectatic VBA is the causative factor [2]. A Pubmed search revealed 12 cases of VA aneurysms presenting with hemifacial spasm. One report describes Foville’s syndrome secondary to a dissecting VA aneurysm [3]. Our first-of-its-kind report demonstrates the simultaneous occurrence of hemifacial spasm and jugular foramen syndrome due to the mass effect of two aneurysms on an ectatic VA loop. Microsurgical clipping and debulking are performed for VA aneurysms causing brainstem compression and neurological deficits [4], while endovascular coiling is an optional in other cases [5]. In our case, the complex nature of the contiguous aneurysms on the VA segment and the need for decompression precluded endovascular intervention. S. V. Furtado (&) S. Thakar N. A. Saikiran A. S. Hegde Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), EPIP Area, Whitefield, Bangalore 560066, Karnataka, India e-mail: sunilvf@gmail.com

Delayed Retraction of the Pipeline Embolization Device and Corking Failure

The safety of flow-diverting stents for the treatment of ruptured intracranial aneurysms is unknown. A 35-year-old woman with a ruptured dissecting aneurysm of the intradural right vertebral artery and incorporating the right posterior inferior cerebellar artery was treated with a Pipeline Embolization Device (PED). Five days after reconstruction of the diseased right vertebral segment, she was treated for vasospasm, and retraction of the PED was observed, leaving her dissecting aneurysm unprotected. A second PED was placed with coverage of the aneurysm, but vasospasm complicated optimal positioning of the device. In addition to the potential risks of dual antiplatelet therapy in these patients, this case illustrates 2 pitfalls of flow-diverting devices in vessels in vasospasm: delayed retraction of the device and difficulty positioning the device for deployment in the setting of vasospasm.

Stent-Assisted Coil Embolization and Computational Fluid Dynamics Simulations of Bilateral Vertebral Artery Dissecting Aneurysms Presenting With Subarachnoid Hemorrhage

A vertebral artery dissecting aneurysm (VADA) is a relatively rare cause of subarachnoid hemorrhage. Bilateral VADAs are even rarer, and management strategies are controversial. We report a case of bilateral VADAs presenting with subarachnoid hemorrhage. We treated the patient by stent-assisted coil embolization of both aneurysms at a single session on the basis of results of preoperative computational fluid dynamic simulations. A 48-year-old man presented with subarachnoid hemorrhage resulting from bilateral VADAs. We treated the patient by stent-assisted coil embolization of both aneurysms at a single session. Before the treatment, we performed computational fluid dynamics simulations to predict the ruptured side. We also estimated the increase in wall shear stress on an aneurysm in case of trapping of another aneurysm, which might cause enlargement and rupture of the aneurysm. The treatment was performed successfully. The patient remains neurologically intact at 14 months from the onset. Stent-assisted coil embolization of subarachnoid hemorrhage with bilateral VADAs for both sides is a reasonable treatment because it prevents rebleeding and preserves bilateral vertebral arteries without increasing hemodynamic stress. To the best of our knowledge, this is the first report to describe this type of treatment for bilateral VADAs with subarachnoid hemorrhage. Computational fluid dynamics simulations may be useful for developing treatment strategies for aneurysms.

E-016 Low cost, efficient, highly effective method for therapeutic arterial occlusion of the internal carotid or vertebral artery with flow control

Therapeutic internal carotid or vertebral artery occlusion is occasionally recommended for a variety of cerebrovascular diseases, including giant aneurysms, vessel ruptures, and arteriovenous fistulae. With the removal of detachable balloons...

Urgent endovascular treatment of ruptured vertebral artery dissecting aneurysms

Objective To summarize and investigate the clinical features and urgent endovascular technique of ruptured vertebral artery dissecting aneurysms (VADA).Method 20 cases of ruptured VADA were retrospectively reviewed to assess the clinical manifestation,imaging characteristics and process of endovascular treatment.Results Total 20 cases of VADA are mainly manifested of spontaneous subarachnoid hemorrhage( or accompanied with hydrocephalus).DSA showed pearl and string sign in 13 cases.Of the 20 cases,18 cases which have well -developed contralateral vertebral arteries were treated by dissecting aneurysm coiling and parent artery occlusion.17 cases survived,with an survival rate of 94％ ( 17/18 ).And no recanalization or recurrence occurred.Conclusions Urgent coil embolization of aneurysm with parent artery occlusion was one of the safe and effective methods on ruptured VADAs. Key words: Vertebral artery; Dissecting aneurysm; Endovascular treatment

Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery

Use of a flow-diverting device has shown promising short-term results in the management of vertebral artery (VA) dissecting aneurysms, but there is still uncertainty regarding its long-term efficacy and safety. The authors report their initial experience with respect to the potential utility and long-term clinical outcomes of using a flow-diverting device in the treatment of unruptured dissecting VA aneurysms. The authors conducted a retrospective review of all cases of unruptured intracranial VA dissecting aneurysms treated at their institution (Tuen Mun Hospital) with a flow-diverting device. They describe the clinical presentations and angiographic features of the cases and report the clinical outcome (with modified Rankin Scale [mRS] scores) at most recent follow-up, as well as results of the latest angiographic assessment, with particular focus on in-stent patency and side-branch occlusion. A total of 4 aneurysms were successfully obliterated by using flow-diverting devices alone. Two devices were deployed in a telescoping fashion in each of 2 aneurysms, whereas only 1 device was inserted in each of the other 2 aneurysms. No periprocedural complication was encountered. No patient showed any angiographic evidence of recurrence, in-stent thrombosis, or side-branch occlusion in angiographic reassessment at a mean of 22 months after treatment (range 18-24 months). As of the most recent clinical follow-up (mean 30 months after treatment, range 24-37 months), all patients had favorable outcomes (mRS Score 0). Reconstruction using a flow-diverting device is an attractive alternative in definitive treatment of dissecting VA aneurysms, demonstrating favorable long-term clinical and angiographic outcomes and the ability to maintain parent artery and side-branch patency. It is particularly useful in cases with eloquent side-branch or dominant VA involvement.

Bilateral Vertebral Artery Dissecting Aneurysms Presenting with Subarachnoid Hemorrhage Treated by Staged Coil Trapping and Covered Stents Graft

The treatment of bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid hemorrhage (SAH) is still challenging. The authors report a rare case of bilateral VADA treated with coil trapping of ruptured VADA and covered stents implantation after multiple unsuccessful stent assisted coiling of the contralateral unruptured VADA. A 44-year-old woman was admitted to our hospital because of severe headache and sudden stuporous consciousness. Brain CT showed thick SAH and intraventricular hemorrhage. Cerebral angiography demonstrated bilateral VADA. Based on the SAH pattern and aneurysm configurations, the right VADA was considered ruptured. This was trapped with endovascular coils without difficulty. One month later, the contralateral unruptured VADA was protected using a stent-within-a-stent technique, but marked enlargement of the left VADA was detected by 8-months follow-up angiography. Subsequently two times coil packing for pseudosacs resulted in near complete occlusion of left VADA. However, it continued to grow. Covered stents graft below the posterior inferior cerebellar artery (PICA) origin and a coronary stent implantation across the origin of the PICA resulted in near complete obliteration of the VADA. Covered stent graft can be used as a last therapeutic option for the management of VADA, which requires absolute preservation of VA flow.

A Case of Lateral Medullary Infarction after Endovascular Trapping of the Vertebral Artery Dissecting Aneurysm

We report an unusual case of lateral medullary infarction after successful embolization of the vertebral artery dissecting aneurysm (VADA). A 49-year-old man who had no noteworthy previous medical history was admitted to our hospital with a severe headache. Computed tomography (CT) revealed a subarachnoid hemorrhage, located in the basal cistern and posterior fossa. Cerebral angiography showed a VADA, that did not involve the origin of the posterior inferior cerebellar artery (PICA). We treated this aneurysm via endovascular trapping of the vertebral artery distal to the PICA. After operation, CT revealed post-hemorrhagic hydrocephalus, which we resolved with a permanent ventriculoperitoneal shunt procedure. Postoperatively, the patient experienced transient mild hoarsness and dysphagia. Magnetic resonance image (MRI) showed a small infarction in the right side of the medulla. The patient recovered well, though he still had some residual symptom of dysphagia at discharge. Such an event is uncommon but can be a major clinical concern. Further investigation to reveal risk factors and/or causative mechanisms for the medullary infarction after successful endovascular trapping of the VADA are sorely needed, to minimize such a complication.

Antegrade Recanalization of Parent Artery after Internal Trapping of Ruptured Vertebral Artery Dissecting Aneurysm

We report a patient with a ruptured vertebral artery (VA) dissecting aneurysm that was treated by internal trapping of the aneurysm and parent artery using detachable coils with subsequent antegrade recanalization of occluded vertebral artery during the follow-up period. A 38-year-old man was admitted with a ruptured right VA dissecting aneurysm just distal to origin of right posterior inferior cerebellar artery. The dissected segment of the VA was occluded by coil embolization. The 14 months follow-up angiography showed that dissected aneurysm was completely occluded, but the parent artery was recanalized in an antegrade fashion. Based on this unique case, the authors suggest that careful angiographic follow-up of dissecting aneurysm is required, even in patients successfully treated with endovascular occlusion of the affected artery and aneurysm.

Altered Hemodynamics Associated with Pathogenesis of the Vertebral Artery Dissecting Aneurysms

The etiology of the vertebral dissecting aneurysms is largely unknown, and they frequently occurs in relatively healthy young men. Objectives and Methods. A series of 57 consecutive cases defined by angiography were evaluated with regard to deviation in the course of the affected and contralateral vertebral arteries. Division was into 3 types: Type I without any deviation, Type II with mild-to-moderate deviation but not over the midline; and Type III with marked deviation over to the contralateral side beyond the midline. Results. The most frequent type of VA running was Type III for the affected and Type I nonaffected side, with this being found in all 17 patients except one. All of the Type III dissections occurred just proximal to a tortuous portion, while in cases with Type-I- and Type-II-affected sides, the majority (33 of 39) occurred near the union of the vertebral artery. In 10 of 57, a non-dominant side was affected, all except one being of Type I or II. With 12 recent patients assessed angiographically in detail for hemodynamics, eleven patients showed contrast material retrograde inflowing into the pseudolumen from the distal portion of the dissection site. Turbulent blood flow was recognized in all of these patients with retrograde inflow. Conclusions. Turbulent blood flow is one etiology of vertebral artery dissection aneurysms, with the sites in the majority of the cases being just proximal to a tortuous portion or union of vessels. In cases with dissection proximal to the tortuous course of the vertebral artery, retrograde inflow will occur more frequently than antegrade, which should be taken into account in designing therapeutic strategies.

Hypoglossal nerve palsy after extensive vomiting

C. Dissection of the left internal carotid artery. Dissection of the internal carotid artery (ICAD; Fig. 1) is not only widely accepted as an important component of stroke aetiology, it is also well recognised as a focal cause of lower cranial nerve palsy.[1]Mokri B. Silbert P.L. Schievink W.I. et al.Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery.Neurology. 1996; 46: 356-359Crossref PubMed Scopus (241) Google Scholar In the present patient, a duplex ultrasound revealed a left, submandibular ICAD originating 3 cm distal to the ICA bifurcation. In parallel, a high-grade, long-distance stenosis was confirmed by a time-of-flight magnetic resonance angiogram. Axial T2-weighted MRI showed a crescent-like, hyperintense signal corresponding to an intramural haematoma. In addition, an asymptomatic dissecting vertebral artery (VA) aneurysm on the right V2-segment was detected. This additional finding was not surprising, since simultaneous dissection of more than one extracranial artery is reported in up to 28% of patients.[1]Mokri B. Silbert P.L. Schievink W.I. et al.Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery.Neurology. 1996; 46: 356-359Crossref PubMed Scopus (241) Google Scholar There was no evidence of either brainstem or supratentorial infarction on MRI. The pathogenesis of extracranial ICAD[1]Mokri B. Silbert P.L. Schievink W.I. et al.Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery.Neurology. 1996; 46: 356-359Crossref PubMed Scopus (241) Google Scholar includes trivial precipitating events such as coughing and sneezing. We speculate that abrupt and extensive rotation of the head and neck during retching and vomiting caused the ICA and VA to suddenly become either stretched or compressed, ultimately leading to intimal tearing and subsequent dissection. In clinical practice, ipsilateral Horner’s syndrome and neck/head pain are recognised as the most common local manifestations of extracranial ICAD. However, cranial nerve palsy also develops in up to 12% of patients with extracranial ICAD, and in almost half of these patients, the hypoglossal nerve is involved either alone or combined with other lower cranial nerve palsies.[1]Mokri B. Silbert P.L. Schievink W.I. et al.Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery.Neurology. 1996; 46: 356-359Crossref PubMed Scopus (241) Google Scholar The anatomical course of the distal hypoglossal nerve in the dorsolateral parapharyngeal space is close to the ICA; therefore, direct compression of the hypoglossal nerve by the expanding intramural haematoma of an extracranial ICAD may manifest clinically as an isolated unilateral hypoglossal nerve palsy.[1]Mokri B. Silbert P.L. Schievink W.I. et al.Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery.Neurology. 1996; 46: 356-359Crossref PubMed Scopus (241) Google Scholar Haemodynamic or even embolic (as for anomalous vessels derived from the ICA) disturbances to the nutrient arteries supplying the cranial nerves can lead to segmental ischemia of the hypoglossal nerve itself.[1]Mokri B. Silbert P.L. Schievink W.I. et al.Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery.Neurology. 1996; 46: 356-359Crossref PubMed Scopus (241) Google Scholar Early diagnosis of ICAD is therefore essential to ensure successful antiplatelet or anticoagulation treatment, since about three-quarters of patients with ICAD eventually develop thromboembolic cerebral ischemia.[2]Baumgartner R.W. Bogousslavsky J. Clinical manifestations of carotid dissection.Front Neurol Neurosci. 2005; 20: 70-76Crossref PubMed Scopus (66) Google Scholar The authors thank Dr. Sandra Dieni for reading the manuscript. Hypoglossal nerve palsy after extensive vomitingJournal of Clinical NeuroscienceVol. 19Issue 5PreviewA previously healthy, 44-year-old woman suffered five to six attacks of retching and extensive vomiting over a period of 30 hours. Metoclopramide (10 mg) was administered intravenously on the emergency ward for antiemetic treatment. Within a few hours the patient experienced a left-sided deviation of the tongue, accompanied by slightly slurred speech, difficulty with food transfer, and left-sided headache and neck pain. Subsequent neurological examination revealed a unilateral left hypoglossal nerve palsy (Fig. Full-Text PDF

Management of ruptured and unruptured intracranial vertebral artery dissecting aneurysms

Vertebral artery dissecting aneurysms (VADA) are challenging disorders for neurosurgeons. Between December 2005 and May 2010, we treated 12 patients for DA of the intracranial VA. Three were treated by open surgery, seven underwent endovascular manipulation, and two were conservatively managed. Nine patients presented with subarachnoid hemorrhage from the ruptured aneurysm, and of these, two experienced abrupt re-hemorrhage and three presented with symptoms of brainstem ischemia. One of the two patients with a re-hemorrhage underwent conservative management and died in hospital of re-bleeding at 30 days after initial presentation. No postoperative neurological deficits occurred in patients treated by open surgery or via an endovascular approach. No re-hemorrhage or ischemic symptoms were observed in the 11 remaining patients during the mean 29-month (range: 14–54-month) follow-up. The chosen management strategy should be developed according to the patient’s clinical condition and imaging results. Endovascular treatment, which includes several techniques, is the first choice for most patients.

Flow-Diverting Stent for Ruptured Intracranial Dissecting Aneurysm of Vertebral Artery

The treatment of ruptured dissecting aneurysms of the intracranial vertebral artery (VA) with parent vessel preservation is a challenge for neurosurgeons and interventional neuroradiologists. To propose an indication for flow-diverting treatment for reconstruction of a dissecting VA with acute subarachnoid hemorrhage. Two male patients transferred after acute subarachnoid hemorrhage and dissecting aneurysm on the V4 segment of the dominant VA. An occlusion test was not performed because of their poor clinical state. A flow-diverting stent represented by the Pipeline embolization device was suggested to both patients. Three Pipeline embolization devices were deployed in each VA. One dissecting aneurysm was excluded immediately after 3 stents, and 1 patient had complete exclusion demonstrated at the 48-hour control. No morbidity directly related to the procedure was observed. No recanalization and no rebleeding occurred during the 3 months of follow-up. A flow-diverting stent may be considered an option to treat ruptured dissecting aneurysms of the VA, providing remodeling of the parent vessel and complete exclusion of the aneurysm.

Strategy for Treating Unruptured Vertebral Artery Dissecting Aneurysms

The natural course of unruptured vertebral artery dissecting aneurysms (VADAs) remains unclear. The purpose of this retrospective study was to develop a strategy for treating unruptured VADAs based on long-term follow-up. Our study population consisted of 100 patients with unruptured VADAs; in 66, the initial symptom was headache only, 30 presented with ischemic symptoms and 4 with mass effect. All underwent magnetic resonance imaging and magnetic resonance angiography at the time of admission and 2 weeks and 1, 3, 6, 12, and 24 months after the onset. If the dissection site was demonstrated to be enlarged on magnetic resonance imaging and magnetic resonance angiography without the manifestation of new symptoms, the patients received additional treatment to prevent bleeding. Of the 100 patients, 4 underwent early intervention because of symptom exacerbation. The other 96 were initially treated conservatively; during follow-up, 5 manifested lesion enlargement on magnetic resonance angiography. Nine patients received additional treatment; 1 underwent direct surgery with trapping of the dissection site, and 8 underwent coil embolization. The other 91 patients continued to be treated conservatively; the dissection site remained unchanged in 70, improved or healed in 18, and disappeared in 3 patients. We treated 38 patients with recurrent ischemic attacks with antiplatelet therapy. No patients experienced bleeding or permanent neurological deficits during follow-up. The nature of an unruptured VADA is not highly aggressive. However, if the dissection site enlarges without the manifestation of new symptoms, it should be occluded. In patients with recurrent ischemic attacks antiplatelet therapy should be considered.

Intraoperative complications of endovascular management for intracranial aneurysms

Objective To summarize the clinical experience of endovascular intervention for intra-cranial aneurysms, especially in the respect of the technique and management of intra-operative complications. Method The clinical data of 60 patients with intra-cranial aneurysms treated with endovascular intervention in the past 3 years were analyzed. The relevant literature especially with regard to the practical technique described was reviewed so as to potentiall minimize and properly manage the intra-operative complications. Results A total of 69 sacciform aneurysms and one dissecting aneurysm located at left vertebral artery (VA) were detected by using digital subtraction angiography (DSA) in 60 patients. There were 65 saccular aneurysms obliterated with constructive approach, and five of them treated with stent-assisted technique and four of them treated with ballon-assisted technique. The VA dissecting aneurysm was obliterated with coils by deconstructive approach with complete occlusion of its parent vessel. There were a total of 53 complete occlusions of aneurysms accounted for 76.81% of 69 sacciform aneurysms in 51 patients ( 85 % ) and eight subtotal occlusion of aneurysms (95 % ～ 99 % occlusion) accounted for 13.56% of total sacciform aneurysms in five patients (8.47%) and four incomplete occlusion of aneurysms ( ＜ 95% occlusion) accounted for 6.78% of total sacciform aneurysms in three patients (5.08%), and one was failure in operation. The rupture of aneurysms occurred during operation in4 patients (6.78%). Two senile patients suffered from intra-opeartive symptomatic thromboembolisn. One patient had stent shifting and spring coil dislocated and moved into the M3 segment of the ipsilateral MCA. Vasospasm occurred in 15 patients during operation, and most of them received endovascular intervention 3 days after the initial ictus. The rate of good recovery was 93.3% at discharge from hospital (the modified Rankin Scales, mRS＜ 2). There were 55 patients followed up for up 24 months after discharge, and excellent recovery rate was found in 51 patients ( mRS ＜ 2), and 3 died.During the follow-up period, no aneurismal recanalization or rupture was noticed in all patients. Conclusions The endovascular intervention is a safe and effective approach to the intra = cranial aneurysms. Advances in the skill of technique and proper management will decrease the complications during operation and improve the prognosis of patients. Key words: Intracranial aneurysm; Endovascular treatment; Coil; Embolization; Subarachnoid hemorrhage; Intraoperative complication; Aneurysm, ruptured; Vasospasm

Surgical treatment of vertebral artery-posterior inferior cerebellar artery dissecting aneurysms

To study an effective method for vertebral artery-posterior inferior cerebellar artery (VA-PICA) dissecting aneurysms. Five patients with VA-PICA dissecting aneurysms were treated surgically between December 2007 and February 2010, who were all males, aged from 40 to 55 years. Four of them presented with subarachnoid hemorrhage (SAH), 1 of them suffered from an intermittent headache on occipital area about 4 months. All the aneurysms were trapped via a far-lateral approach after revascularization of the PICAs by occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass. Among the 5 patients, 1 of them got a good outcome without any neurological deficit after surgery, 3 of them had postoperative lower cranial nerve palsy, 1 of them complicated with bleeding in the operative field after postoperative antithrombotic treatment, and suffered from contralateral hemiplegia after second surgery of removing hematoma. Postoperative cerebral angiographies (received by 2 patients) and CT angiographies (received by 3 patients) all showed patent bypasses and no filling of the aneurysms. During the follow-up from 2 to 29 months, 4 patients got good outcomes, 1 patient still suffered from moderate hemiplegia. Trapping the aneurysms after revascularization of PICA by OA-PICA bypass should be an effective method to treat the VA-PICA dissecting aneurysms, but individualized strategies also need to be considered based on different cases.

Successful Treatment of Bilateral Vertebral Artery Dissecting Aneurysms with Subarachnoid Hemorrhage: Report of Three Cases

Vertebral artery dissecting aneurysm (VADA) is a relatively rare cause of subarachnoid hemorrhage (SAH). Bilateral VADAs are even rare, and management strategies for this type of VADAs are still controversial. Here, we report 3 cases of bilateral VADAs with SAH. All 3 patients were treated conservatively under strict sedation and blood pressure control during the acute stage. During the course, rebleeding was not observed in any case. One patient underwent trapping of the ruptured VADA on day 28, because this lesion was considered to have a high tendency to rebleed, even in the chronic stage. In the other 2 patients, after conservative treatment, the VADAs spontaneously resolved on the both sides. As for the therapeutic strategy for bilateral VADAs presenting with SAH, at the acute stage, considering the difficulty of bypass surgery, we recommend conservative treatment with sedation and strict control of blood pressure. At the chronic stage, however, when the VADA is still large and growing in size, surgical treatment such as proximal occlusion or trapping of the affected VA with or without distal revascularization should be considered to avoid rebleeding.

Endovascular Treatment of Vertebral Artery Dissection Using Stents and Coils: Its Pitfall and Technical Considerations

There are various options for the treatment of vertebral artery dissection aneurysms (VADA). Treatment with stents may be an effective method to treat VADA involving the posterior inferior cerebellar artery (PICA) and dissection of the dominant vertebral artery (VA). In this article, our personal experience of the treatment of VADAs by using stents and coils is reported. Since 1998, 26 cases of VADA have been treated by endovascular surgery by the first author. Of these cases, 6 cases were treated using stents, 3 of which were treated using stent and coils, 2 patients were treated using double overlapping stents, and the remaining one patient was treated using a single stent. In all patients, dissection aneurysms were successfully covered by stents. There was one complication: an intraprocedural rupture during additional coil insertion without neurological deterioration. Follow-up angiography was performed in all 5 surviving patients except for one patient who died due to the severity of his original subarachnoid hemorrhage (mean duration of follow-up angiography 22.8 months, range 15-57 months). Total or subtotal disappearance of the VADA was achieved in all 5 cases. At one year after the treatment, all 5 surviving patients remained clinically stable without any neurological deficit. Treatment using stents is an effective alternative for the treatment of VA dissecting aneurysms, especially for lesions of the dominant VA or involving the PICA. However, additional coil insertion should be performed very carefully and may be avoided if stagnation of contrast material is achieved after overlapping stenting.

Clinical outcomes of lower cranial nerve palsies caused by vertebral artery–posteroinferior cerebellar artery aneurysms after endovascular embolization

Objective: To report clinical outcomes of lower cranial nerve palsy (LCNP) caused by vertebral artery (VA) aneurysms.Methods: Seventy-two patients with VA aneurysms, who were treated endovascularly between 2001 and 2008, were retrospectively studied to identify patients presenting LCNP without hemorrhage.Results: LCNP occurred in 12 patients (16·7%) initially caused by VA aneurysms: four located at vertebral artery–posteroinferior cerebellar artery (PICA) complex, seven at distal to PICA segment and one at proximal to PICA segment. Among these patients, ten patients were diagnosed as having dissecting aneurysms of the intracranial VA, and two were diagnosed having saccular aneurysms. Two patients were treated by sole stent placement, five patients were treated by stent coil embolization and five were treated by vertebral artery occlusion. Nosocomial pneumonia did not occur in our patients. Post-operative LCNP resolved completely within 6 months in nine patients (75%) and within 9 months in ten patients (83%). Two (1·9%) patients died of aneurismal bleeding and brainstem ischemia, respectively.Conclusion: The results of this study can help to identify the effect and natural history of LCNP caused by VA aneurysms. These lesions can be effectively treated by endovascular embolization, even by VA occlusion.

E-034 Endovascular internal trapping for ruptured dissecting vertebral artery aneurysms

PurposeRuptured dissecting vertebral artery aneurysms should be treated immediately because of the high risk of rebleeding.The purpose of this retrospective study is to evaluate the efficacy of endovascular internal trapping...