Endovascular strategies for vertebrobasilar dissecting aneurysms

Abstract

Background and purpose: Dissecting vertebrobasilar aneurysms are challenging to treat, and standard treatment modalities remain controversial. We retrospectively evaluated our experience using endovascular techniques to treat these aneurysms.

Materials and methods: From February 1997 to December 2007, 42 patients with intradural vertebrobasilar dissecting aneurysms underwent endovascular treatment. Twenty-nine patients had ruptured aneurysms, and 13 patients had unruptured dissecting aneurysms. The endovascular modalities for vertebrobasilar dissecting aneurysms were the following: 1) trapping (n = 30), 2) proximal occlusion (n = 3), 3) stent with coil (n = 6), and 4) stent alone (n = 3).

Results: Seventeen of the 29 patients with ruptured vertebrobasilar dissecting aneurysms had successful outcomes without procedural complications following endovascular treatment. Procedure-related complications were the following: 1) rebleeding (n = 3), 2) posterior inferior cerebellar artery (PICA) territory infarction (n = 6), 3) brain stem infarction (n = 2), and 4) thromboembolism-related multiple infarctions (n = 1). Clinical outcomes were favorable in 32 patients (76.1%). There were 3 (7.1%) procedure-related mortalities due to rebleeding, and 1 (2.4%) non-procedure-related mortality due to pneumonia sepsis. All 13 patients with unruptured vertebrobasilar dissecting aneurysms had favorable clinical and radiologic outcomes without procedure-related complications.

Conclusions: Endovascular procedures for treatment of unruptured symptomatic dissecting aneurysms resulted in favorable outcomes. Ruptured vertebrobasilar dissecting aneurysms are associated with a high risk of periprocedural complications. Risks can be managed by using appropriate endovascular techniques according to aneurysm location, configuration, and relationship with the PICA.

Fig 1.

Case 5 of an unruptured vertebrobasilar dissecting aneurysm. A, Anteroposterior angiogram of the left VA shows the pearl sign with an approximately 6-mm pseudoaneurysm. B, Anteroposterior angiogram of the left VA 3 months later demonstrates marked enlargement of the pseudoaneurysm. C and D, Anteroposterior and lateral angiograms of the left VA after trapping with coils show complete occlusion of distal left VA and pseudoaneurysm.

Fig 2.

Case 14 of an ruptured vertebrobasilar dissecting aneurysm. A and B, Anteroposterior and lateral angiograms of the left VA demonstrate a pearl-and-string sign with an approximately 5-mm pseudoaneurysm in the basilar artery. C, Anteroposterior angiogram of the left VA immediately after deployment of a balloon-expandable stent into the dissected basilar lesion and occlusion of pseudoaneurysm with 4 Guglielmi detachable coils. D, Follow-up anteroposterior angiogram of the left VA 11 days later shows good patency of the basilar artery with occlusion of the pseudoaneurysm.