Treatment Outcomes of Stent-Assisted Coil Embolization for Ruptured Vertebral Artery Dissecting Aneurysms: The Preservation of Branches May Improve the Prognosis

Abstract

Objective: Subarachnoid hemorrhage due to ruptured vertebral artery dissecting aneurysm (rVADA) is associated with a high frequency of acute rebleeding and requires early treatment following onset. Parent artery occlusion (PAO) or stent-assisted coiling (SAC) embolization is selected as a treatment option according to the individual patient condition. This report is a retrospective examination evaluating the treatment outcomes for rVADA.

Methods: The subjects were 20 rVADA patients (16 men and 4 women) who underwent endovascular treatment at our institution. The mean patient age was 52.9 years. Ten patients each were allocated to the PAO group and SAC group. We evaluated and compared the following parameters: presence of hemorrhagic complications, presence of ischemic complications, requirement of retreatment, and Glasgow Outcome Scale (GOS) after 90 days.

Results: The reasons for selecting SAC were contralateral occlusion or a small diameter in three patients, the posterior inferior cerebellar artery (PICA) involvement in three patients, perforating artery from dissected lesion in five patients, and anterior spinal artery in one patient. There was no rebleeding in any patient. Symptomatic ischemic complications were observed in four patients in the PAO group and in one in the SAC group. Hyper-intense lesions in the brainstem on MRI DWI were noted in five patients in PAO group and in one in the SAC group. Retreatment was required for three patients in the PAO group and for four in the SAC group. Favorable outcomes (GOS 4, 5) after 90 days were observed for three patients in the PAO group and for eight patients in the SAC group (p = 0.0257).

Conclusion: SAC that can preserve branches is a useful treatment option for rVADA. Further studies on a greater number of subjects are required to establish the optimal dose of antiplatelet agents and anticoagulants, and for stent selection.

Keywords: endovascular treatment; preservation of branches; ruptured vertebral artery dissecting aneurysm; stent-assisted coil embolization; treatment results.

Fig. 1. GOS after 90 days. Clinical outcomes were compared between PAO and SAC. P means the PAO group and S means the SAC group. The prognosis was significantly favorable in the SAC group (p = 0.0257, OR: 0.36; 0.11–0.81). GOS: Glasgow Outcome Scale; PAO: parent artery occlusion; SAC: stent-assisted coiling

Fig. 2. A 62-year-old man. (A) CT showing the subarachnoid hemorrhage. (B) DSA showing the pearl and string sign in left vertebral artery distal to the posterior inferior cerebellar artery. (C) Three-dimensional rotational angiography showing the patent right vertebral artery. Post-procedural DSA showing antegrade flow from the right VA to the basilar artery (D) and from the left VA to the PICA (E). (F) Postoperative MRI showing left paramedian medullary infarction. CT: computed tomography; DSA: digital subtraction angiography; MRI: magnetic resonance imaging; PICA: posterior inferior cerebellar artery; VA: vertebral artery

Fig. 3. A 46-year-old man. (A) CT showing the subarachnoid hemorrhage in the prepontine cistern. (B) DSA showing the dissected aneurysm in the right vertebral artery. (C) Cone-beam CT showing the perforating artery originating from the dissected lesion. The perforating artery was successfully preserved on cone-beam CT after stent placement (C) and after coil embolization on DSA (D). (E) MRI DWI the next day revealed no infarction in the brainstem. CT: computed tomography; DSA: digital subtraction angiography; MRI DWI: magnetic resonance imaging diffusion-weighted imaging