OBJECTIVE Vertebrobasilar dissecting (VBD) aneurysms are rare, and patients with these aneurysms often present with thromboembolic infarcts or subarachnoid hemorrhage (SAH). The morphological nature of VBD aneurysms often precludes conventional clip reconstruction or coil placement and encourages parent artery exclusion or endovascular stenting. Treatment considerations include aneurysm location along the vertebral artery (VA), the involvement of the posterior inferior cerebellar artery (PICA), and collateral blood flow. Outcomes after endovascular treatment have been well described in the neurosurgical literature, but microsurgical outcomes have not been detailed. Patient outcomes from a large, single-surgeon, consecutive series of microsurgically managed VBD aneurysms are presented, and 3 illustrative case examples are provided. METHODS The medical records of patients with dissecting aneurysms affecting the intracranial VA (V4), basilar artery, and PICA that were treated microsurgically over a 19-year period were reviewed. Patient demographics, aneurysm characteristics, surgical procedures, and clinical outcomes (according to modified Rankin Scale [mRS] scores at last follow-up) were analyzed. RESULTS Forty-two patients with 42 VBD aneurysms were identified. Twenty-six aneurysms (62%) involved the PICA, 14 (33%) were distinct from the PICA origin on the V4 segment of the VA, and 2 (5%) were located at the vertebrobasilar junction. Thirty-four patients (81%) presented with SAH with a mean Hunt and Hess grade of 3.2 at presentation. Six (14%) of the 42 patients had been previously treated using endovascular techniques. Nineteen aneurysms (45%) underwent clip wrapping, 17 (40%) were treated with bypass trapping, and 6 (14%) underwent parent artery sacrifice. The complete aneurysm obliteration rate was 95% (n = 40), and the surgical complication rate was 7% (n = 3). The 8 patients with unruptured VBD aneurysms were significantly more likely to be discharged home (n = 6, 75%) compared with 34 patients with ruptured aneurysms (n = 9, 27%; p = 0.01). Good outcomes (mRS score ≤ 2) were observed in 20 patients (48%). Eight patients (19%) died. CONCLUSIONS These data demonstrate that patients with VBD aneurysms often present after a rupture in poor neurological condition, but favorable results can be achieved with open microsurgical repair in almost half of such cases. Microsurgery remains a viable treatment option, with the choice between bypass trapping and clip wrapping largely dictated by the specific location of the aneurysm and its relationship to the PICA.
Background Vertebral artery dissecting aneurysms (VADAs) are a rare cause of subarachnoid hemorrhage associated with high rates of morbidity and mortality. Ruptured non-dominant VADAs are traditionally treated via endovascular coil-occlusion. However, controversy exist for the appropriate management of unruptured VADAs and ruptured dominant VADAs. To the authors knowledge, this is the largest single-center study comparing modern neuroendovascular neurosurgical treatment strategies, including flow diversion (FD), to treat VADAs. Methods All patients with a VADA treated endovascularly at a single center from January 1st, 1999 to December 31st, 2019 were retrospectively analyzed from a prospectively collected database. VADAs were categorized as either dominant or nondominant vertebral artery. Furthermore, location of the VADA was classified as either the proximal V4 segment of the vertebral artery (proximal to PICA), incorporating PICA origin, or (distal V4) distal to PICA. Primary neurological outcomes were measured via mRS, with a mRS >2 categorized as a poor neurological outcome and a decline in mRS from the preoperative neurological exam as a worse neurological outcome. Secondary outcomes included retreatment rate and complications. Results 91 patients underwent endovascular treatment for a VADA over this 20-year period (44 patients underwent open microsurgical intervention). 77 (85%) VADAs were on the proxmial V4 segment, 8 (9%) included the PICA origin, and 6 (7%) arose distal to PICA. Coil-occlusion was performed in 47 (51%), FD in 29 (32%), and stent/coil in 15 (17%) cases. 54 patients (59%) presented with SAH (treated via coil-occlusion in 39, FD in 7, and stent/coil in 8 cases; p<0.001) and 44 VADAs (48%) involved a dominant vertebral artery (all dominant vertebral arteries were treated by either a FD or stent/coil; p<0.001). Rates of complications and retreatment were both significantly higher in patients treated with stent/ coil (complication: N=4, 27%, retreatment: N=6, 40%) vs either coil-occlusion (complication: N=1, 2%, retreatment=2, 4%) or FD (complication: N=2, 7%, retreatment: N=4, 14%) (p=0.008 and p=0.002, respectively). Preoperative mRS was significantly higher in patients treated with coil-occlusion (3.2±1.4)than FDD (1.9±1.5)or stent/coil (1.8±1.3) (p<0.001). Likewise, coil-occlusion (22, 46%) was associated with a higher percentage of patients with a mRS >2 on follow-up than FDD (4, 14%) or stent/coil (3, 20%) (p=0.006). For dominant vertebral arteries, stent/coil (6, 40%) required greater percentage of retreatments than FD (4, 14%) (p=0.049). Of the unruptured VADAs (N=37), 1 patient suffered a complication (3%), 4 patients (11%) required retreatment, 2 patients (5%) had mRS >2, and 8 patients (22%) exhibited a decline in mRS on follow-up, with no significant difference between the treatments. Conclusion The majority of ruptured VADAs at our center were treated by coil-occlusion of non-dominant vertebral artery. For dominant vertebral arteries, FD required less retreatment than stent/coil ...
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