Evolving strategies in the management of vertebral artery dissecting aneurysms involving the posterior inferior cerebellar artery: a systematic review and meta-analysis

Abstract

Background: Vertebral artery dissecting aneurysms (VADAs) involving the posterior inferior cerebellar artery (PICA) origin present a unique therapeutic challenge due to high rupture risk, complex anatomy, and the critical need to preserve brainstem perfusion. Despite the increasing use of endovascular strategies, no prior meta-analysis has specifically evaluated outcomes for this clinically high-risk subgroup.

Objective: To systematically review and quantitatively synthesize available data on the endovascular management of VADAs involving the PICA origin.

Methods: A comprehensive literature search of PubMed and Scopus was conducted per PRISMA guidelines. Studies reporting clinical outcomes for VADAs involving the PICA origin treated with endovascular techniques were included. Pooled estimates were calculated for key outcomes using a random-effects meta-analysis model. Heterogeneity and publication bias were assessed.

Results: This review included 141 patients. The majority (90.1%) presented with ruptured aneurysms. In the literature, stent-assisted coiling (SAC) was the most frequently employed reconstructive strategy, with a 12.5% recurrence rate (95% CI: 6-24%) and a 20% rebleeding rate (95% CI: 12-38%, p < 0.001) according to one-arm proportional meta-analysis. The overall complete occlusion following endovascular therapy was 49.2% (95% CI: 94-100%). PICA patency was preserved in 43.7% of cases. The overall ischemic complication rate was 15.6%, and mortality was 6.4%, predominantly in patients undergoing deconstructive treatments. Most patients achieved favorable neurological outcomes (mRS ≤ 2).

Conclusions: Flow diversion appears to be a promising option for PICA-involving VADAs, demonstrating comparable early occlusion rates with no reported re-bleeding in the limited cases available, and a lower tendency to recur compared with SAC. SAC retains value in anatomically favorable, nondominant lesions, though its higher rebleeding risk limits its use when branch hemodynamics are complex. Larger, prospective multicenter studies are needed to refine flow-diverter protocols and define the specific circumstances in which adjunctive or stent-assisted techniques remain advantageous.

Clinical trial: Not applicable.

Keywords: Dissecting aneurysm; Endovascular treatment; Neurological outcomes; Posterior inferior cerebellar artery; Vertebral artery.