Subarachnoid Hemorrhage from Intracranial Arterial Dissection in the Vertebrobasilar System: Factors Related to Subsequent Rupture, and Surgical Results

Abstract

Summary:In ruptured intracranial arterial dissection of the vertebrobasilar system, subsequent rupture is one of the poor prognostic factors. We analyzed the factors related to the subsequent rupture and compared the surgical results of craniotomy with those of intravascular surgery. Among 154 patients with vertebrobasilar arterial dissection, 92 presented with subarachnoid hemorrhage.Fifty-six patients were surgically treated: 35 had craniotomies (proximal occlusion or trapping), and 21 had intravascular surgery (internal trapping or proximal occlusion).Subsequent rupture occurred in 29% (27/92), and was observed mostly on the day of onset. Among the various clinical and radiological factors, a history of arterial hypertension, a poor Hunt and Kosnik grade (3-5), and a pearl and string sign on the angiogram were significantly more frequent in the patients with subsequent rupture. The long-term outcomes in the craniotomy group were generally equal to those in the intravascular group. When the analysis was limited to acute stage, the results of the surgical treatment were unchanged between the 2 groups. In addition, the incidence of postoperative ischemic complication did not differ significantly between the 2 groups.These results suggest that a history of arterial hypertension, a poor Hunt and Kosnik grade and the pearl and string sign are significant factors correlated with subsequent rupture. Surgical treatment may be indicated for patients with the above 3 factors, both craniotomy and intravascular surgery.