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

Abstract

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.

Deconstructive and Reconstructive Techniques in Treatment of Vertebrobasilar Dissecting Aneurysms: A Systematic Review and Meta-Analysis

“…[7][8][9] Higher rates of longterm angiographic occlusion with multiple overlapping stents compared with single-stent treatment have been demonstrated in multiple series. [10][11][12] Our study found similar rates of good long-term neurologic outcome between patients treated with reconstructive and deconstructive techniques but higher rates of perioperative morbidity among patients treated with deconstructive techniques. Patients treated with deconstructive techniques are at a higher risk of neurologic complications secondary to ischemia resulting from sacrifice of the parent vessel.…”

“…However, these complications are rare. 7,10,12 The most important consideration in the treatment of VBDA is weighing the risks of treatment with the risks of the natural history of these lesions. Ruptured VBDA are known to have a poor natural history with high rates of rebleeding and mortality.…”

Aneurysm wall enhancement on magnetic resonance imaging as a risk factor for progression of unruptured vertebrobasilar dissecting aneurysms after reconstructive endovascular treatment

“…16 In this study, the rates of both complete obliteration and metal coverage were higher in the stable group than that in the progression group, although the difference was not statistically significant. However, we still think the 2 factors were important for aneurysm recurrence after reconstructive EVT, and we always strive to achieve dense embolism of the aneurysm and high metal coverage of the stent in the aneurysm neck (e.g., overlapping stents) in our clinical practice.…”

“…1,7,16 These reported risk factors include aneurysm size, patient age, stent number, and immediate obliteration grade of the aneurysm sac. 1,7,16 However, few of these studies included the stability of the arterial wall as a risk factor. VBDA is more likely to represent a disease of the vessel wall than a disease of the vessel lumen.…”

“…This finding has been reported by many authors. 16 Large VBDAs, which are believed to develop from small, unstable VBDAs, might be even less stable than small VBDAs. Additionally, large VBDAs generally have a longer dissecting segment and aneurysm neck, making them difficult to completely occlude.…”