Coil embolization for the treatment of ruptured dissecting vertebral aneurysms

Abstract

Background and purpose: Proximal occlusion of the parent artery has been widely used for treatment of vertebral dissecting ruptured aneurysms, but this does not always completely prevent rerupture. We retrospectively studied 24 consecutive patients for clinical characteristics and/or for efficacy of occlusion with detachable coils at the site of dissection.

Methods: During a 45-month period, 24 of 242 patients with aneurysms associated with subarachnoid hemorrhage had dissecting vertebral aneurysms identified at angiography. Eighteen of the 24 patients were treated with platinum coil occlusion at the affected site as early as possible after diagnosis, two patients were treated conservatively, and four others were not eligible for treatment owing to intractable elevation of intracerebral pressure and severe brain stem dysfunction.

Results: The rate of aneurysmal rupture in the posterior fossa was high, at 56 (23%) of the 242 aneurysms, including 24 (10%) vertebral dissecting aneurysms. Subsequent rupture occurred in 14 (58%) of the patients, all within 24 hours after the first attack and three during transportation to the hospital. In all 18 patients, coil embolization at the affected site was successful, with no complications. Radiologic findings showed complete occlusion of the dissection site and patency of the unaffected artery (mean follow-up, 9 months). Among the six patients who did not undergo embolization, only one survived with a good outcome, the others died of repeat hemorrhage.

Conclusion: A high rate of vertebral artery dissecting aneurysms may be expected in patients with subarachnoid hemorrhage, especially in those with early repeat hemorrhage. Detachable platinum coil embolization may be more effective than proximal occlusion for treatment of ruptured vertebral dissecting aneurysms because of immediate cessation of blood flow to the dissection site; however, in patients with bilateral dissections or hypoplastic contralateral vertebral arteries, prior bypass surgery orstent placement to preserve the artery will be needed.

fig 1.

Case 2. A, Right vertebral angiogram on day 1, anterolateral view, shows no abnormal findings. B, Follow-up right vertebral angiogram on day 7 shows a dissecting aneurysm in the vertebral artery, distal to the PICA origin. C, Right vertebral angiogram immediately after embolization of the dissection site. D, Follow-up MR angiogram 7 months after embolization.

fig 2.

Case 5. A, Right vertebral artery angiogram, anterolateral view, shows a dissecting aneurysm distal to the PICA origin. B, Right vertebral angiogram, anterolateral view, immediately after coil embolization of the dissection site. C, Left vertebral angiogram, anterolateral view, shows an increase in diameter relative to that before embolization. D, Follow-up right vertebral angiogram, anterolateral view, 1 month after embolization shows complete occlusion of the affected site and preservation of the PICA.

fig 3.

Case 13. A–E, Initial right (A) and left (B) vertebral angiograms on day 0 show bilateral vertebral artery dissection. Angiograms on day 2 show marked dilatation of the left vertebral artery dissecting aneurysm before (C) and after (D) coil embolization. Follow-up right vertebral angiogram on day 10 (E) shows progressive dissection.