Vertebral Artery Dissecting Aneurysms Research Articles

Radical treatment for bilateral vertebral artery dissecting aneurysms by reconstruction of the vertebral artery.

OBJECTIVE Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery. METHODS Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms. RESULTS The post-coil embolization patients underwent V3-posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V3-V4 or V4-V4 bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable. CONCLUSIONS Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V3-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.

Posterior inferior cerebellar artery reimplantation: buffer lengths, perforator anatomy, and technical limitations.

OBJECTIVE Reimplantation of the posterior inferior cerebellar artery (PICA) to the vertebral artery (VA) is a safe and effective bypass option after deliberate PICA sacrifice during the treatment of nonsaccular and dissecting aneurysms at this location. However, the anatomy and limitations of this technique have not been studied. The goal of this study was to define the surgical anatomy and buffer lengths specific to the proximal segment of the PICA related to 2 variations of PICA reimplantation: 1) reimplantation "along-VA" (simulating a dissecting VA aneurysm), and 2) reimplantation "across-VA" (simulating a nonclippable, proximal PICA aneurysm). METHODS Ten cadaver heads (20 sides) were prepared for surgical simulation. Twenty far-lateral approaches were performed. The PICA was mobilized and reimplanted onto the VA according to 2 different paradigms: 1) transposition along the axis of the VA (along-VA) to simulate a dissecting VA, and 2) transposition perpendicular to the axis of the VA (across-VA) to simulate a nonclippable, proximal PICA aneurysm. The buffer lengths provided by mobilization of the artery in each paradigm were measured and the anatomy of perforator branching on the proximal PICAs was analyzed. RESULTS The PICA was reimplanted in all surgical simulations. The most common perforating artery on the P1 and P2 segments was the short circumflex type. No direct perforator was found on the P1 segment. The mean buffer length with reimplantation along the VA axis was 13.43 ± 4.61 mm, and it was 6.97 ± 4.04 mm with reimplantation across the VA. The PICA was less maneuverable when it was reimplanted across the VA, due to perforator branches of the PICA (P3 segment). CONCLUSIONS The buffer lengths measured in this study describe the limitations of PICA reimplantation as a revascularization procedure for nonsaccular aneurysms in this location. PICA reimplantation is a revascularization option for dissecting VA aneurysms incorporating the PICA origin that are < 13 mm in length, and for nonsaccular proximal PICA aneurysms that are < 6 mm in diameter. The final decision to reimplant the PICA depends on careful inspection of perforator anatomy that is not visible preoperatively on angiography, as well as an assessment of technical difficulty intraoperatively.

Long-Term Outcome of Tubridge Flow Diverter(S) in Treating Large Vertebral Artery Dissecting Aneurysms—A Pilot Study

The experience of flow diverters (FDs) in treating large vertebral artery-dissecting aneurysms (VADAs) is still limited. This study was conducted to present our long-term outcome of VADAs treated with a Tubridge flow diverter (TFD), a new device developed in China. The clinical and angiographic data of six patients harboring large VADAs and treated with TFDs were prospectively collected and analyzed. A total of nine TFDs were successfully implanted in six patients. Angiographic follow-up images were available for all patients at a median of 26.0 (18.5, 37.5) months after treatment. Five of the six VADAs were completely occluded, and the last was improved (near complete occlusion). In-stent stenosis was detected in one case and was handled appropriately by angioplasty and stenting. All covered branches and parent arteries remained patent. There were no complications or new neurological deficits observed in any of the patients. At the latest clinical follow-up (36.5 (26.0, 44.5) months), all patients achieved 0 in the modified Rankin scale score. Our preliminary experience suggests that the Tubridge flow diverter might be an alternative treatment for large and recurrent dissecting aneurysms derived from the vertebral artery.

Safety and effectiveness of endovascular treatment for ruptured vertebral artery dissecting aneurysms in the acute stage

Background- Ruptured vertebral artery dissecting aneurysms (VADA) should be treated promptly because of the high risk of rebleeding. However, it is difficult to treat dissecting aneurysm during the acute stage by microsurgery because of high intracranial pressure or brain edema. Therefore, endovascular treatment of the ruptured VADA may be a better technique. We retrospectively studied the efficacy and outcome of endovascular treatment of ruptured VADA in the acute stage. Methods- Nineteen patients with ruptured VADA received endovascular treatment in the acute stage. Among them, 17 were treated by internal trapping of the dissected segment. We performed stent-assisted coiling for a case of VADA in the contralateral hypoplastic VA and a case of bilateral dissection (ruptured VADA of the right VA and dissection of the left VA).Results- Seven patients (37%) had good recovery, 3 patients (26%) had moderate disability, 3 patients (16%) had severe disability, one patient (5%) entered a persistent vegetative state, and 3 patients (16%) died. There was no recurrent hemorrhage after endovascular treatment, but complications related to the endovascular procedures occurred in 3 patients.Conclusion- Endovascular treatment of ruptured VADA in the acute stage appears to be safe and effective.

Therapeutic Progress in Treating Vertebral Dissecting Aneurysms Involving the Posterior Inferior Cerebellar Artery.

Among the variations of vertebral artery dissecting aneurysms (VDAs), VDAs involving the posterior inferior cerebellar artery (PICA), especially ruptured and high-risk unruptured aneurysms, are the most difficult to treat. Because the PICA is an important structure, serious symptoms may occur after its occlusion. Retained PICAs are prone to re-bleeding because VDAs are difficult to completely occlude. There is therefore confusion regarding the appropriate treatment for VDAs involving the PICA. Here, we used the PubMed database to review recent research concerning VDAs that involve the PICA, and we found that treatments for VDAs involving the PICA include (i) endovascular treatment involving the reconstruction of blood vessels and blood flow, (ii) occluding the aneurysm using an internal coil trapping or an assisted bypass, (iii) inducing reversed blood flow by occluding the proximal VDA or forming an assisted bypass, or (iv) the reconstruction of blood flow via a craniotomy. Although the above methods effectively treat VDAs involving the PICA, each method is associated with both a high degree of risk and specific advantages and disadvantages. The core problem when treating VDAs involving the PICA is to retain the PICA while occluding the aneurysm. Therefore, the method is generally selected on a case-by-case basis according to the characteristics of the aneurysm. In this study, we summarize the various current methods that are used to treat VDAs involving the PICA and provide schematic diagrams as our conclusion. Because there is no special field of research concerning VDAs involving the PICA, these cases are hidden within many multiple-cases studies. Therefore, this study does not review all relevant documents and may have some limitations. Thus, we have focused on the mainstream treatments for VDAs that involve the PICA.

Endovascular Treatment of Symptomatic Vertebral Artery Dissecting Aneurysms.

ObjectiveVertebral artery dissecting aneurysms (VADAs) are rare and many debates are present about treatment options. We review types and efficacy of our endovascular treatments and establish a safe endovascular therapeutic strategy regard to the angio-architecture of VADAs.Materials and MethodsBetween July 2008 and October 2015, we treated 22 patients with symptomatic VADAs. Fifteen patients presented with subarachnoid hemorrhage from the ruptured VADAs, digital subtraction angiography and magnetic resonance image confirmed the diagnosis and endovascular treatments were followed as their angio-architecture.ResultsClinical results were good in 13 patients (86.7%), and there were no technical problems during endovascular procedures. The other 2 patients with poor prognosis showed severe neurological deficits at the initial evaluation. Among the three different endovascular treatments, there were no radiologic cure in one patient with stent insertion alone, but the patient had no significant clinical symptoms either.ConclusionEndovascular treatments are safe and effective treatment option for managing VADAs and can be the first treatment of choice for most patients. To select proper endovascular treatment according to the angio-architecture of VADAs can reduce the risk of the treatment.

Surgical Treatment of Complex Cerebral Aneurysms Using Interposition Short Vein Graft.

Cerebral revascularization strategies may become necessary in select patients who present with challenging cerebral aneurysms. In this study, we present the techniques of a moderate-flow extra-intracranial bypass using a short interposition vein graft and concurrent aneurysm management. The short interposition vein graft was used for the reconstruction of complex cerebral aneurysms in nine patients. In eight of them, the superficial temporal artery (STA) main trunk was used as a donor site for the anastomosis of a short interposition vein graft, and an extracranial vertebral artery (VA) was used in one case. The vein grafts were implanted into the M2 of the middle cerebral artery (MCA) for the adjunctive treatment of internal carotid artery (ICA) aneurysms in three patients, into the A3 of the anterior cerebral artery (ACA) in one patient, into the P2 of the posterior cerebral artery (PCA) for the adjunctive treatment of complex PCA aneurysms in three patients, into the P3 of the PCA for the adjunctive treatment of a basilar artery (BA) trunk giant aneurysm in 1 patient, and into the postero-inferior cerebellar artery (PICA) for the adjunctive treatment of the VA dissecting aneurysm in one patient. All of the bypasses were patent. Intraoperative flow measurements confirmed a moderate flow-carrying capacity of the short interposition short vein graft (30-70 ml; mean: 43 ml/min). The STA main trunk to proximal MCA/PCA bypass and the extracranial VA to PICA bypass using short interposition vein grafts can provide sufficient blood flow and may be a reasonable alternative to the conventional EC-IC bypass/high-flow bypass.

Endovascular reconstruction of unruptured intradural vertebral artery dissecting aneurysms with the Pipeline embolization device

BackgroundDissecting aneurysms of the vertebral artery (VA) are difficult to treat using current surgical and endovascular techniques.ObjectiveTo analyze retrospectively the efficacy and safety of flow diverters in the treatment of...

Endovascular parent vessel sacrifice in ruptured dissecting vertebral and posterior inferior cerebellar artery aneurysms: clinical outcomes and review of the literature

BackgroundRuptured intracranial dissecting aneurysms must be secured quickly to prevent re-hemorrhage. Endovascular sacrifice of the diseased segment is a well-established treatment method, however postoperative outcomes of symptomatic stroke and re-hemorrhage...

Endovascular Treatment of Intracranial Vertebral Artery Dissecting Aneurysms: Follow up Angiographic and Clinical Results of Endovascular Treatment in Serial Cases.

PurposeTo report angiographic and clinical results of endovascular treatment in 45 intracranial vertebral artery dissecting aneurysms (VADAs).Materials and MethodsFrom July 2002 to September 2013, a total of 42 patients with 45 VADAs received endovascular treatment. Endovascular treatment consisted of internal trapping with detachable coils, stent-assisted coiling, and stenting only. Immediate and follow-up angiographic findings and clinical outcome were retrospectively reviewed.ResultsThere were 17 ruptured VADAs and 28 unruptured VADAs. Overall, 26 VADAs were treated with internal trapping, 14 with stent-assisted coil embolization, and 5 with stenting only. Immediate angiographic results revealed complete occlusion in 31 cases and incomplete occlusion in 14 cases. Follow-up imaging studies were available in 31 cases. On follow-up imaging, antegrade recanalization occurred in 2 of 16 cases treated with internal trapping. Aneurysmal recurrence occurred in one case treated with stent-assisted coiling. Procedural complications occurred in 8 patients. In cases of unruptured VADA, favorable outcome (mRS 0 and 1) was achieved in 26 cases and poor outcome (mRS 2-5) in 2 cases. There was no mortality in patients with unruptured VADAs.ConclusionEndovascular treatment of intracranial VADA appears to be safe and effective. Follow-up angiographic study is needed because parent artery recanalization or aneurysmal recurrence can occur.

Endovascular Treatment of Vertebral Artery Dissecting Aneurysms That Cause Subarachnoid Hemorrhage : Consideration of Therapeutic Approaches Relevant to the Angioarchitecture.

ObjectiveIntracranial ruptured vertebral artery dissecting aneurysms (VADAns) are associated with high morbidity and mortality when left untreated due to the high likelihood of rebleeding. The present study aimed to establish an endovascular therapeutic strategy that focuses specifically on the angioarchitecture of ruptured VADAns.MethodsTwenty-three patients with ruptured VADAn received endovascular treatment (EVT) over 7 years. The patient group included 14 women (60.9%) and 9 men (39.1%) between the ages of 39 and 72 years (mean age 54.2 years). Clinical data and radiologic findings were retrospectively analyzed.ResultsFour patients had aneurysms on the dominant vertebral artery. Fourteen (61%) aneurysms were located distal to the posterior inferior cerebellar artery (PICA). Six (26%) patients had an extracranial origin of the PICA on the ruptured VA, and 2 patients (9%) had bilateral VADAns. Eighteen patients (78%) were treated with internal coil trapping. Two patients (9%) required an adjunctive bypass procedure. Seven patients (30%) required stent-supported endovascular procedures. Two patients experienced intra-procedural rupture during EVT, one of which was associated with a focal medullary infarction. Two patients (9%) exhibited recanalization of the VADAn during follow-up, which required additional coiling. No recurrent hemorrhage was observed during the follow-up period.ConclusionEVT of ruptured VADAns based on angioarchitecture is a feasible and effective armamentarium to prevent fatal hemorrhage recurrence with an acceptable low risk of procedural complications. Clinical outcomes depend mainly on the pre-procedural clinical state of the patient. Radiologic follow-up is necessary to prevent hemorrhage recurrence after EVT.

Treatment of ruptured vertebral artery dissecting aneurysms distal to the posterior inferior cerebellar artery: stenting or trapping?

The treatment of ruptured vertebral artery dissecting aneurysms (VADAs) continues to be controversial. Our goal was to evaluate the safety, efficacy, and long-term outcomes of internal trapping and stent-assisted coiling (SAC) for ruptured VADAs distal to the posterior inferior cerebellar artery (supra-PICA VADAs), which is the most common subset. A retrospective review was conducted of 39 consecutive ruptured supra-PICA VADAs treated with internal trapping (n = 20) or with SAC (n = 19) at our institution. The clinical and angiographic data were retrospectively compared. The immediate total occlusion rate of the VADAs was 80 % in the trapping group, which improved to 88.9 % at the follow-ups (45 months on average). Unwanted occlusions of the posterior inferior cerebellar artery (PICA) were detected in three trapped cases. Incomplete obliteration of the VADA or unwanted occlusions of the PICA were detected primarily in the VADAs closest to the PICA. In the stenting group, the immediate total occlusion rate was 47.4 %, which improved to 100 % at the follow-ups (39 months on average). The immediate total occlusion rate of the VADAs was higher in the trapping group (p < 0.05), but the later total occlusion was slightly higher in the stenting group (p > 0.05). Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although not statistically significant, procedural related complications occurred more frequently in the trapping group. When the VADAs are close to the PICA, we suggest that the lesions should be treated using SAC.

Endovascular interventional therapy and classification of vertebral artery dissecting aneurysms.

The current study aimed to summarise the clinical features and classifications of vertebral artery dissecting aneurysms (VADAs) to optimise strategies for endovascular interventional therapy. The clinical features and results of 31 inpatients with VADA were retrospectively analysed. The aneurysms were classified according to their location and association between the aneurysm and posterior inferior cerebellar artery (PICA), and into subtypes according to the developmental state of the contralateral vertebral artery. Different endovascular interventional therapy strategies were selected for each classification. Three types of aneurysm with two subtypes each were identified. An aneurysm located distally to the PICA was termed type I (10/31 patients). Aneurysms with a contralateral vertebral artery were denoted as subtype a (type Ia, 6/31 patients) and aneurysms with hypoplasia of the contralateral vertebral artery were denoted as subtype b (type Ib, 4/31 patients). An aneurysm located at the origin of the PICA was termed type II (13/31 patients), with seven cases classified as IIa and six cases as IIb. An aneurysm located proximally to the PICA was termed type III (8/31 patients), with five cases classified as IIIa and three cases as IIIb. Among the 31 patients, 18 received stent-assisted coiling, two received coiling, 10 received coiling with parent artery occlusion and one patient received conservative treatment. Among the 31 patients with VADA, 21 were occluded completely, nine were partially occluded and one was not occluded. One patient developed a coma following coiling; however, the other 30 patients recovered well. Thus, the classification of an aneurysm based on its location and the developmental state of the contralateral vertebral arteries appears to be an effective and safe approach for the selection of appropriate endovascular interventional therapy strategies.

The interaction between stent(s) implantation, PICA involvement, and immediate occlusion degree affect symptomatic intracranial spontaneous vertebral artery dissection aneurysm (sis-VADA) recurrence after reconstructive treatment with stent(s)-assisted coiling.

ObjectivesWe aimed to evaluate risk factors of sis-VADAs recurrence after reconstructive treatment based on 113 reconstructed lesions.MethodsA total of 111 patients (M:F = 68:43; median age, 47 years) with 113 sis-VADAs underwent reconstruction from October 2000 to March 2011, using stent(s) and coils. Treatments and predictors of recurrence were retrospectively analysed.ResultsFifty-eight sis-VADAs underwent single-stent treatment, and the remaining 55 sis-VADAs underwent treatment with 2-4 overlapping stents. Follow-up angiography was available for 94 sis-VADAs 12 -78 months, with recurrence in ten patients, including seven angiographic recurrences and three post-treatment haemorrhagic recurrences. A higher rate of post-treatment recurrence was observed in the single stent group than in the multiple stents group (p = 0.010). The interaction between stent (s) implantation and immediate occlusion degree (odds ratio [OR] =3.152; 95 % confidence interval [CI], 1.293-7.686; p = 0.012), between stent (s) implantation and the posterior inferior cerebellar artery (PICA) involvement (OR = 4.607; 95 % CI, 1.172-18.113; p = 0.029), and between PICA involvement and immediate occlusion degree (OR = 5.018; 95 % CI, 1.263-19.933; p = 0.022) affect recurrence in the reconstructed sis-VADAs.ConclusionsThis single centre cohort study indicated that the interaction effect between stent (s) implantation, PICA involvement, and immediate occlusion degree were closely associated with recurrence after reconstructive treatment of sis-VADA.Key Points• The interaction between stent (s) and immediate occlusion degree affect aneurysmal recurrence • The interaction between stent and PICA involvement affect aneurysmal recurrence • The interaction between PICA involvement and immediate occlusion degree affect aneurysmal recurrence Electronic supplementary materialThe online version of this article (doi:10.1007/s00330-014-3225-7) contains supplementary material, which is available to authorized users.

Management of Hemorrhagic Dissecting Vertebral Artery Aneurysms Involving Posterior Inferior Artery

We reported 2 cases with hemorrhagic dissecting vertebral artery (VA) aneurysms involving posterior inferior cerebellar artery (PICA), and one was treated with aneurysm trapping and PICA-VA anastomosis, whereas another was treated with coil embolization and VA-to-PICA stent placement. We suggest both bypass surgery and VA-to-PICA stent placement are good options for PICA revascularization.

Long-term outcomes of trapping vertebral artery-posterior inferior cerebellar artery dissecting aneurysms after revascularization

This study is designed to evaluate the long-term outcome of trapping vertebral artery-posterior inferior cerebellar artery (VA-PICA) dissecting aneurysms after revascularization. Five patients with VA-PICA dissecting aneurysms were treated surgically between 2007 and 2010. All the aneurysms were trapped through a far-lateral approach after revascularization of the PICAs by occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass. All patients were scheduled for clinical follow-up in the out-patient department at 3 months, 6 months, then annually. Computed tomography (CT) scan and CT angiography, or magnetic resonance (MR) imaging and MR angiography were performed to assess the anastomosis and cerebral blood supply. Among the five patients, two of them did not have any neurological deficit after surgery, the other three had post-operative lower cranial nerve palsy but recovered completely within 6 months. Post-operative cerebral angiography (received by two patients) and CT angiography (received by the other three patients) showed patent bypasses in all patients and there was no reappearance of the aneurysms. After following-up from 47 to 74 months (61 month is the median follow-up period), all patients showed excellent outcomes. Trapping the aneurysms after revascularization of PICAs by OA-PICA bypass is a safe method to treat the VA-PICA dissecting aneurysms.

Endovascular Treatment for Ruptured Vertebral Artery Dissecting Aneurysms: Results from Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2

In treating ruptured vertebral artery dissecting aneurysms (VADAs), neuroendovascular therapy (NET) represented by coil obliteration is considered to be a reliable intervention. However, there has been no multi-center based study in this setting so far. In this article, results of NET for ruptured VADA obtained from Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2 were assessed to elucidate the factors associated with favorable outcome. A total of 213 in JR-NET1 and 381 patients in JR-NET2 with ruptured VADA were included, and they were separately analyzed because several important datasets such as vasospasm and site of dissecting aneurysms in relation to the posterior inferior cerebellar artery (PICA) were collected only in JR-NET1. The ratio of poor World Federation of Neurosurgical Societies (WFNS) grade (4 and 5) was 48.8% and 53.9%, and the ratio of favorable outcome (modified Rankin scale, mRS 0 to 2) at 30 days after onset was 61.1 % and 49.1% in JR-NET1 and 2, respectively. In both studies, poor WFNS grade and procedural complication were independently correlated as negative factors for favorable outcome. In JR-NET1, PICA-involved lesion was also designated as a negative factor while elderly age and absence of postprocedural antithrombotic therapy was detected as other negative factors in JR-NET2. The ratios of favorable outcome in poor grade patients were 25.4% in JR-NET1 and 31.3% in JR-NET2, which seemed compatible with the previous studies. These results may provide a baseline data for the NET in this disease and could be useful for validating the benefits of novel devices.

Reconstructive Treatment of Ruptured Intracranial Spontaneous Vertebral Artery Dissection Aneurysms: Long-Term Results and Predictors of Unfavorable Outcomes

IntroductionFew studies focused on predictors of unfavorable outcomes (modified Rankin Scale, 2–6) after reconstructive treatment of the ruptured intracranial spontaneous vertebral artery dissection aneurysms (ris-VADAs), which was evaluated based on 57 reconstructed lesions in this study.MethodsResults of 57 consecutive patients (M:F = 29∶28; median age, 48 years; range, 27 to 69 years) harboring 57 ris-VADAs, which were treated with coils combined with single stent(n = 32), double overlapping stents (n = 16), and triple overlapping stents (n = 9) between October 2000 to March 2011, were retrospectively reviewed and analyzed.ResultsThe available (n = 54) mean durations of angiographic and clinical follow-ups were 27 months (range, 12 to 78) and 62 months (range, 12 to 132), respectively. The involvement of PICA (p = 0.004), size of lesions (p = 0.000), quantity of stent (p = 0.001), and coil type (p = 0.002) affected the immediate obliteration grade, which was only risk factor for angiographic recurrences (p = 0.031). Although the post-treatment outcomes did not differ between single stent and multiple stents (p = 0.434), 5 angiographic recurrences, 1 rebleeding and 1 suspected rebleeding, all occurred in partial obliteration after single-stent-assisted coiling. Progressive thrombosis and in-stent obliteration were not detected on follow-up angiograms. Older age (odds ratio [OR] = 1.090; 95% confidence interval [CI], 1.004–1.184; p = 0.040) and unfavorable Hunt-Hess scale (OR = 4.289; 95%CI, 1.232–14.933; p = 0.022) were independent predictors of unfavorable outcomes in the reconstructed ris-VADAs.ConclusionsImmediate obliteration grade was only risk factor for angiographic recurrence after reconstructive treatment. Unfavorable Hunt-Hess grade and older age were independent predictors of unfavorable outcomes in ris-VADAs.

Dissecting Aneurysm of Vertebral Artery Manifestating as Contralateral Abducens Nerve Palsy

Isolated abducens nerve paresis related to ruptured vertebral artery (VA) aneurysm is rare. It usually occurs bilaterally or ipsilaterally to the pathologic lesions. We report the case of a contralateral sixth nerve palsy following ruptured dissecting VA aneurysm. A 38-year-old man was admitted for the evaluation of a 6-day history of headache. Abnormalities were not seen on initial computed tomography (CT). On admission, the patient was alert and no signs reflecting neurologic deficits were noted. Time of flight magnetic resonance angiography revealed a fusiform dilatation of the right VA involving origin of the posterior inferior cerebellar artery. The patient suddenly suffered from severe headache with diplopia the day before the scheduled cerebral angiography. Neurologic examination disclosed nuchal rigidity and isolated left abducens nerve palsy. Emergent CT scan showed high density in the basal and prepontine cistern compatible with ruptured aneurismal hemorrhage. Right vertebral angiography illustrated a right VA dissecting aneurysm with prominent displaced vertebrobasilar artery to inferiorly on left side. Double-stent placement was conducted for the treatment of ruptured dissecting VA aneurysm. No diffusion restriction signals were observed in follow-up magnetic resonance imaging of the brain stem. Eleven weeks later, full recovery of left sixth nerve palsy was documented photographically. In conclusion, isolated contralateral abducens nerve palsy associated with ruptured VA aneurysm may develop due to direct nerve compression by displaced verterobasilar artery triggered by primary thick clot in the prepontine cistern.

Endovascular Coil Trapping of a Ruptured Dissecting Aneurysm of the Vertebral Artery Using Detachable Coils and Micro-Tornado® Coils

We experienced a patient with a ruptured dissecting aneurysm of the vertebral artery who was treated by trapping of the lesion using Guglielmi detachable coils (GDCs) with micro-tornado® coils (MTCs). An 80-year-old male was transferred with a ruptured left vertebral artery dissecting aneurysm (VADA). The dissected portion of the vertebral artery was effectively trapped using GDCs and MTCs. The MTCs used for neurointervention were comprised of various types of coils and we successfully placed them into the parent artery of the dissected segment. The author suggests that this case demonstrates the usefulness of endovascular coil trapping of VADAs using MTCs in achievement of embolization.