Endovascular interventional therapy and classification of vertebral artery dissecting aneurysms

Abstract

The current study aimed to summarise the clinical features and classifications of vertebral artery dissecting aneurysms (VADAs) to optimise strategies for endovascular interventional therapy. The clinical features and results of 31 inpatients with VADA were retrospectively analysed. The aneurysms were classified according to their location and association between the aneurysm and posterior inferior cerebellar artery (PICA), and into subtypes according to the developmental state of the contralateral vertebral artery. Different endovascular interventional therapy strategies were selected for each classification. Three types of aneurysm with two subtypes each were identified. An aneurysm located distally to the PICA was termed type I (10/31 patients). Aneurysms with a contralateral vertebral artery were denoted as subtype a (type Ia, 6/31 patients) and aneurysms with hypoplasia of the contralateral vertebral artery were denoted as subtype b (type Ib, 4/31 patients). An aneurysm located at the origin of the PICA was termed type II (13/31 patients), with seven cases classified as IIa and six cases as IIb. An aneurysm located proximally to the PICA was termed type III (8/31 patients), with five cases classified as IIIa and three cases as IIIb. Among the 31 patients, 18 received stent-assisted coiling, two received coiling, 10 received coiling with parent artery occlusion and one patient received conservative treatment. Among the 31 patients with VADA, 21 were occluded completely, nine were partially occluded and one was not occluded. One patient developed a coma following coiling; however, the other 30 patients recovered well. Thus, the classification of an aneurysm based on its location and the developmental state of the contralateral vertebral arteries appears to be an effective and safe approach for the selection of appropriate endovascular interventional therapy strategies.

Keywords: dissecting aneurysms; endovascular interventional therapy; vertebral artery.

Figure 1

(A) Digital subtraction angiography (DSA) and (B) 3D-DSA images showing a well-developed type Ia dissecting aneurysm of the left vertebral artery located distally to the posterior inferior cerebellar artery (PICA) and the contralateral vertebral artery. (C) DSA images of the right vertebral artery and (D) an amplified image of the left vertebral artery. The aneurysm was treated with coiling combined with left vertebral artery occlusion. The post-treatment angiograms show complete obliteration of the aneurysm, (E) occlusion of the distal part of the left vertebral artery and (F) a well-filled PICA.

Figure 2

(A) Digital subtraction angiography (DSA) and (B) 3D-DSA images showing a type Ib dissecting aneurysm of the left vertebral artery located distally to the posterior inferior cerebellar artery and the contralateral vertebral artery, exhibiting hypoplasia. DSA images showing the (C) right vertebral artery and (D) stent-assisted coiling treatment of the left vertebral dissecting aneurysm. The post-treatment angiograms show (E) complete obliteration of the aneurysm and (F) that the left vertebral artery was filled well.

Figure 3

(A) Digital subtraction angiography (DSA) and (B) oblique DSA images showing a well-developed type IIa dissecting aneurysm of the left vertebral artery located at the origin of the posterior inferior cerebellar artery (PICA) and the contralateral vertebral artery. (C) DSA image of the right vertebral artery and (D) negative image showing the left vertebral dissecting aneurysm following coiling. The post-treatment angiograms show complete obliteration of the aneurysm, (E) occlusion of the left vertebral artery and (F) the PICA filled with blood from the right vertebral artery.

Figure 4

(A) Digital subtraction angiography (DSA) and (B) oblique DSA images showing a well-developed type IIa dissecting aneurysm of the right vertebral artery located at the origin of the posterior inferior cerebellar artery and the contralateral vertebral artery. DSA images showing the (C) left vertebral artery and (D) stent-assisted coiling treatment of the right vertebral artery. The post-treatment angiograms show (E) complete obliteration of the aneurysm and (F) that the right vertebral artery was filled well.

Figure 5

(A) Computed tomography angiography image showing the bilateral vertebral artery. (B) Negative and (C) 3D digital subtraction angiography (DSA) images showing a well-developed type IIIa dissecting aneurysm of the right vertebral artery located proximally to the posterior inferior cerebellar artery and the contralateral vertebral artery. The aneurysm was treated with coiling combined with right vertebral artery occlusion. (D) DSA image of the left vertebral artery. The post-treatment angiograms show (E) complete obliteration of the aneurysm and (F and G) occlusion of the distal part of the right vertebral artery. (H) Negative image of the right vertebral artery following treatment.

Figure 6

(A) Digital subtraction angiography (DSA) and (B) amplified DSA images showing a well-developed type IIIa dissecting aneurysm of the right vertebral artery located proximally to the posterior inferior cerebellar artery and the contralateral vertebral artery. DSA images showing the (C) left vertebral artery and (D) stent-assisted coiling treatment of the right vertebral dissecting aneurysm. The post-treatment angiograms show (E) complete obliteration of the aneurysm and (F) that the right vertebral artery was filled well.