Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling

Abstract

Background and purpose: Endovascular treatment with stent placement or stent-assisted coiling was recently introduced as an alternative to parent artery occlusion in intracranial vertebral artery dissections. We describe the efficacy and limitations of this method.

Methods: Fourteen patients with intracranial vertebral artery dissection were treated with stent placement (10 patients) or stent-assisted coiling (4 patients). Double overlapping stents were deployed in 4 of 10 patients with stent placement alone. Angiographic follow-up at 6 to 12 months was available in 13 patients.

Results: In 13 patients with dissecting aneurysm, immediate angiographic outcomes were complete occlusion (1 patient), nearly complete (2 patients), and incomplete (10 patients). Follow-up angiograms of 12 of these patients showed complete occlusion (6 patients) and incomplete (6 patients; 1 unstable and 5 stable). Complete occlusion rates in follow-up angiograms were superior in double stent placement (75%) or stent-assisted Guglielmi detachable coil (GDC) embolization to stent placement alone (0%). There were no instances of postprocedural ischemic attacks, new neurologic deficits, and no new minor or major strokes before patient discharge. On the modified Rankin scale applied in follow-up, all patients were assessed as functionally improved or of stable clinical status.

Conclusions: Intracranial vertebral artery dissections were acceptably treated with stent placement or stent-assisted coiling, and the patency could be preserved at follow-up. However, the efficiency of stent placement alone for intracranial vertebral artery dissecting aneurysm was limited. Stent-assisted coil embolization or double stent placements are a viable alternative for complete occlusion of dissecting aneurysms.

Fig. 1.

Images from the case of a 50-year-old woman (patient 7) who had a fusiform aneurysm of the distal intracranial left vertebral artery. A, Anteroposterior projection angiogram of the left vertebral artery disclosed a fusiform aneurysm of the distal intracranial portion (arrow) that is proximal to the vertebrobasilar junction and distal to the left posterior inferior cerebellar artery (PICA, double arrows). B, Unsubtracted image demonstrates the deployed stent (arrows) across the aneurysm. C, Anteroposterior projection angiogram obtained immediately after stent placement demonstrates no change in the fusiform aneurysm. D, Angiogram obtained 19 months after stent deployment reveals no occlusion of the aneurysm.

Fig. 2.

Angiograms in a 37-year-old man (patient 5) with dissecting aneurysm of the distal intracranial left vertebral artery treated with double stent method. A, Anteroposterior projection shows a dissecting aneurysm of the distal intracranial left vertebral artery (arrow). B, Angiogram obtained immediately after double stent placement demonstrates partial resolution of the aneurysm. C, Angiogram obtained 6 months after double stent placement demonstrates complete healing of the aneurysm with restoration of the normal lumen.

Fig. 3.

Angiograms in a 52-year-old man (patient 11) with dissecting aneurysm of the distal intracranial right vertebral artery treated with stent-assisted coiling. A, The stent was placed across the aneurysm neck. B, The aneurysm is occluded incompletely with coils. C, Digital subtraction angiogram shows nearly completely occluded aneurysm with preservation of the parent artery.

Fig. 4.

Images from the case of a 55-year-old woman (patient 9) who had suffered SAH from a wide-necked aneurysm of the distal intracranial right vertebral artery. A, Anteroposterior projection angiogram of the right vertebral artery disclosed an aneurysm of the distal intracranial portion that is proximal to the vertebrobasilar junction and distal to the right posterior inferior cerebellar artery. B, The aneurysm was occluded near completely with coils. C, Angiogram obtained 3 months after stent-assisted coiling demonstrates recanalization of the neck.