Endovascular Treatment of Vertebral Artery Dissecting Aneurysms using Stents

Abstract

We report on five patients who were treated by stent-assisted coil embolization to preserve the patency of the parent artery. Three patients presented with subarachnoid haemorrhage and two with ischemic symptoms. Four patients were treated with stenting and then followed by coil embolization of the aneurysmal dilatation, and the remaining patient with stenting alone because the aneurysmal dilatation was too small to insert coils. Complete obliteration of the aneurysm was achieved in three patients, but in one patient an aneurysmal rupture occurred during the insertion of the first coil and a parent artery occlusion was therefore performed. In the one patient treated with stenting alone, a small aneurysmal dilatation remained patent, but complete obliteration was confirmed by the follow-up angiography. Subsequent subarachnoid haemorrhage was not observed in any of the patients. Four of them achieved a good recovery, but one patient suffered severe disability due to the aneurysmal rupture during the procedure. Parent artery occlusion remains the treatment of choice. Stentassisted coil embolization has a higher risk of rupture than does the parent artery occlusion during the procedure. Furthermore, recanalization or subsequent subarachnoid haemorrhage is more likely to occur in a stent-assisted coil embolization after the procedure. However, this procedure, which can maintain the patency of the parent artery, will become an alternative for patients who are at a high risk of developing ischemic symptoms in parent artery occlusions.

Figure 1

(Case 1). A 52-year-old man presenting with SAH. Antero-posterior (A) and lateral views (B) of the right vertebral angiogram (VAG) showing a "distal to PICA" type dissecting aneurysm. The ASA (arrow) originates in the base of aneurysm. C) Nonsubtracted fluoroscopic image showing perforation of the coil and the microcatheter during insertion of the first coil after stenting. D) Oblique view of the right VAG showing extravazation of the contrast medium. The parent artery occlusion was therefore performed. E) Right VAG obtained two months later showing recanalization of the parent artery and complete obliteration of the aneurysm.

Figure 2

(Case 2). A 48-year-old man presenting with brain stem infarction. A) Oblique view of the right VAG showing a "distal to PICA" type dissecting aneurysm. The PICA originates near the aneurysm and the ASA originates in the affected VA. B) Right VAG after stenting showing that the aneurysmal dilatation became smaller, but remained patent.

Figure 3

(Case 3). A 60-year-old man presenting with SAH. Right (A) and left (B) VAG showing bilateral dissections, a string sign on the right and an aneurysmal dilatation on the left. C) Nonsubtracted fluoroscopic image after stenting. D) Left VAG after coil embolization showing complete obliteration of the aneurysm. E) Nonsubtracted VAG showing the stent and coils.