Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: review of 21 consecutive cases

Multimodal Neuroimaging of Intimal Flap in a Basilar Artery Dissection

This case report describes a spontaneous dissection of the basilar artery in a 53-year-old man presenting with ischemic stroke.

Predictive Factors of Recurrence after Endovascular Treatment of Unruptured Vertebrobasilar Fusiform Aneurysms

PURPOSE

This study aimed to investigate the predictive factors of recurrence after endovascular treatment (EVT) for unruptured vertebrobasilar fusiform aneurysms (VBFA).

METHODS

This single-center retrospective study evaluated 36 patients who underwent EVT of unruptured VBFA between 2008 and 2020. Variables influencing recurrence, such as size, type, thrombus, preoperative symptoms, and treatment methods, were analyzed. All patients were followed up using vessel imaging.

RESULTS

In total, 7 of 36 patients (19.4%) developed recurrence. The mean time from EVT to recurrence was 9.2 months (range 2-26.9 months). Maximum aneurysmal diameter on magnetic resonance imaging was decreased, increased, and remained unchanged in 1, 7, and 28 patients, respectively. Transitional type VBFA, brain compression symptoms, large aneurysmal diameter and length, preoperative modified Rankin Scale (mRS) score ≥ 2, sole stenting technique, and intra-aneurysmal thrombus significantly influenced the risk of recurrence. Post-EVT, 7 (19.4%) patients showed complete occlusion of the aneurysm on the immediate postoperative angiogram, and 22 (61.1%) patients showed complete occlusion on the 1‑year follow-up imaging. Good outcomes were observed in 32 patients (88.9%) at the last follow-up, with a mRS score of 0-1 after EVT.

CONCLUSION

EVT achieves good outcomes in unruptured VBFA. Transitional type VBFA, brain compression symptoms, large aneurysmal diameter and length, preoperative mRS score ≥ 2, sole stenting technique, and intra-aneurysmal thrombus are risk factors for aneurysm recurrence after EVT.

Role of imaging in penetrating vascular injuries of the craniocervical region

Penetrating vascular injury has become the topic of interest with increased gun violence in the United States. The radiologist plays a crucial role in establishing and systemizing the signs of vascular injury such as intimal flap, dissection, pseudoaneurysm, rupture, and arteriovenous fistula. Various imaging techniques such as ultrasound Doppler, computed tomographic angiography (CTA), magnetic resonance angiography, and conventional angiography are being employed based on clinical recommendations. Of all the techniques, CTA has been shown to embrace a promising role in identifying vascular injuries with superior sensitivity, specificity, and accuracy. An acquaintance of the imaging features has been shown to improve the approach to trauma patients in clinical settings. This article details the imaging modalities and the features of the head-and-neck penetrating vascular injury.

Antiplatelets Versus Anticoagulation in Cervical Artery Dissection: A Systematic Review and Meta-analysis of 2064 Patients

Background and Objectives

In young people aged < 50 years, cervical artery dissection (CeAD) is among the most common causes of stroke. Currently, there is no consensus regarding the safest and most effective antithrombotic treatment for CeAD. We aimed to synthesize concrete evidence from studies that compared the efficacy and safety of antiplatelet (AP) versus anticoagulant (AC) therapies for CeAD.

Methods

We searched major electronic databases/search engines from inception till September 2021. Cohort studies and randomized controlled trials (RCTs) comparing anticoagulants with antiplatelets for CeAD were included. A meta-analysis was conducted using articles that were obtained and found to be relevant. Mean difference (MD) with 95% confidence interval (CI) was used for continuous data and odds ratio (OR) with 95% CI for dichotomous data.

Results

Our analysis included 15 studies involving 2064 patients, 909 (44%) of whom received antiplatelets and 1155 (56%) received anticoagulants. Our analysis showed a non-significant difference in terms of the 3-month mortality (OR 0.47, 95% CI 0.03–7.58), > 3-month mortality (OR 1.63, 95% CI 0.40–6.56), recurrent stroke (OR 0.97, 95% CI 0.46–2.02), recurrent transient ischaemic attack (TIA) (OR 0.93, 95% CI 0.44–1.98), symptomatic intracranial haemorrhage (sICH) (OR 0.38, 95% CI 0.12–1.19), and complete recanalization (OR 0.70, 95% CI 0.46–1.06). Regarding primary ischaemic stroke, the results favoured AC over AP among RCTs (OR 6.97, 95% CI 1.25–38.83).

Conclusion

Our study did not show a considerable difference between the two groups, as all outcomes showed non-significant differences between them, except for primary ischaemic stroke (RCTs) and complete recanalization (observational studies), which showed a significant favour of AC over AP. Even though primary ischaemic stroke is an important outcome, several crucial points that could affect these results should be paid attention to. These include the incomplete adjustment for the confounding effect of AP–AC doses, frequencies, administration compliance, and others. We recommend more well-designed studies to assess if unnecessary anticoagulation can be avoided in CeAD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40268-022-00398-z.

ESO guideline for the management of extracranial and intracranial artery dissection

The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Acute hemorrhagic cerebral artery dissection: Characteristics and endovascular treatment

OBJECTIVE

Acute hemorrhagic cerebral artery dissection may show a subtle stenosis and bulge on an angiogram, for which diagnosis and treatment are difficult. This report describes seven cases of acute hemorrhagic cerebral artery dissection treated by endovascular techniques.

PATIENTS AND METHODS

From January 2018 to April 2019, seven patients (22-76 years old) were diagnosed with subarachnoid hemorrhage caused by cerebral artery dissection. Six patients were treated by low-profile visualized intraluminal support stent-assisted coiling and there was a sacrifice of the posterior cerebral artery in one patient. Cerebral angiography results were obtained immediately after intervention and at follow-up. Clinical outcome was evaluated by a modified Rankin Scale score.

RESULTS

Four dissections were angiographic changes of subtle stenosis and small bulges; three were apparent angiographic changes of stenosis or fusiform morphologies. All seven aneurysms were completely obliterated, a low-profile visualized intraluminal support stent was used in six patients and coil occlusion of the parent artery in one patient. Complications occurred in two cases of proximal posterior cerebral artery dissection. One bleeding complication was observed intra-procedure and one ischemic complication was observed after stent-assisted coiling. The angiographic and clinical follow-up was obtained at 3-8 months in five patients. Good recovery was achieved for six patients (modified Rankin Score 0); one patient who presented Weber syndrome caused by ischemic complication had a modified Rankin Score of two at 8 months follow-up.

CONCLUSION

Hemorrhagic cerebral artery dissection may show subtle stenosis, small bulges or fusiform morphologies on angiograms. Treatment of proximal posterior cerebral artery dissection is challenging. Endovascular reconstruction with a low-profile visualized intraluminal support stent was effective depending on the angiographic morphology.

A Case of Subarachnoid Hemorrhage with Dissecting Aneurysm of the Anterior Choroidal Artery

Objective

Dissecting aneurysms of the anterior choroidal artery (AchoA) are extremely rare, with only a few reported cases. Herein, we report an extremely rare case of subarachnoid hemorrhage with dissecting aneurysm of the AchoA.

Case Presentation

A 68-year-old man was hospitalized for sudden onset of headache, progressive consciousness disorder, and right hemiparesis. He had a prior medical history of systemic lupus erythematosus (SLE), and was taking prednisolone (50 mg/day) for 15 months. CT showed subarachnoid hemorrhage in the left side of the basal cistern and Sylvian fissure. Left internal carotid artery (ICA) angiography revealed a fusiform aneurysm of the AchoA. He was diagnosed with a ruptured dissecting aneurysm of the AchoA because the shape of aneurysm was fusiform and there was laminar flow inside the aneurysm. Parent artery occlusion (PAO) was performed to prevent re-hemorrhage on the day of onset. Although ventricular drainage for acute hydrocephalus was performed after AchoA occlusion, his consciousness disorder did not improve. Postoperative angiography at 1-week recovery from the procedure revealed disappearance of the AchoA, including the dissecting aneurysm. However, he died following septic shock caused by pneumonia at 1 month after the procedure.

Conclusion

We report an extremely rare case of subarachnoid hemorrhage with a dissecting aneurysm of the AchoA. Vasculitis caused by SLE and a vulnerability of the vessel wall following chronic steroid use are potential causes of the dissecting aneurysm of the AchoA.

Single-stage endovascular treatment of subarachnoid hemorrhage related to bilateral vertebral artery dissecting aneurysms

OBJECTIVE

Treatment of bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage remains challenging as bilateral deconstructive procedures may not be feasible. In this case series, we describe our approach to their management and review the pertinent literature.

METHOD

A retrospective review of our prospectively collected database on aneurysms was performed to identify all patients with acute subarachnoid hemorrhage in the setting of bilateral intradural vertebral artery dissections (VAD) encompassing a period from January 2000 and March 2012.

RESULT

Four patients (M/F = 2/2; mean age, 51.5 years) were identified. In two cases the site of rupture could be identified by angiographic and cross-sectional features; in these patients deconstructive treatment (proximal obliteration or trapping) of the ruptured site and reconstructive treatment of the unruptured site (using stents and coils) were performed. In the patients in whom the site of hemorrhage could not be determined, bilateral reconstructive treatment was performed. No treatment-related complications were encountered. Modified Rankin scale scores were 0-1 at discharge, and on follow-up (mean 63 months), no recurrence, in-stent thrombosis or new neurological deficits were encountered.

CONCLUSION

We believe that single-stage treatment in patients with bilateral VAD is indicated: If the site of hemorrhage can be determined, we prefer deconstructive treatment on the affected site and reconstructive treatment on the non-affected site to prevent increased hemodynamic stress on the unruptured but diseased wall. If the site of dissection cannot be determined, we prefer bilateral reconstructive treatment to avoid increasing hemodynamic stress on the potentially untreated acute hemorrhagic dissection.

Flow diverter placement for management of dissecting ruptured aneurysm in a non-fused basilar artery

Intracranial vertebral artery dissection can be associated with subarachnoid hemorrhage (SAH) and pseudoaneurysm formation. Dissecting aneurysms have a high risk of rebleeding in the acute phase. To our knowledge, the management of an acute vertebrobasilar junction dissecting aneurysm associated with a basilar non-fusion has not been previously reported. We report here a case of SAH due to rupture of a dissecting aneurysm involving the vertebrobasilar junction and extending to involve the right limb and proximal junction of a non-fused basilar artery, managed by insertion of a flow-diverting stent with excellent clinical outcome and long-term patency of the flow diverter.

Endovascular Treatment of Vertebral Artery Dissecting Aneurysms That Cause Subarachnoid Hemorrhage : Consideration of Therapeutic Approaches Relevant to the Angioarchitecture

Objective

Intracranial ruptured vertebral artery dissecting aneurysms (VADAns) are associated with high morbidity and mortality when left untreated due to the high likelihood of rebleeding. The present study aimed to establish an endovascular therapeutic strategy that focuses specifically on the angioarchitecture of ruptured VADAns.

Methods

Twenty-three patients with ruptured VADAn received endovascular treatment (EVT) over 7 years. The patient group included 14 women (60.9%) and 9 men (39.1%) between the ages of 39 and 72 years (mean age 54.2 years). Clinical data and radiologic findings were retrospectively analyzed.

Results

Four patients had aneurysms on the dominant vertebral artery. Fourteen (61%) aneurysms were located distal to the posterior inferior cerebellar artery (PICA). Six (26%) patients had an extracranial origin of the PICA on the ruptured VA, and 2 patients (9%) had bilateral VADAns. Eighteen patients (78%) were treated with internal coil trapping. Two patients (9%) required an adjunctive bypass procedure. Seven patients (30%) required stent-supported endovascular procedures. Two patients experienced intra-procedural rupture during EVT, one of which was associated with a focal medullary infarction. Two patients (9%) exhibited recanalization of the VADAn during follow-up, which required additional coiling. No recurrent hemorrhage was observed during the follow-up period.

Conclusion

EVT of ruptured VADAns based on angioarchitecture is a feasible and effective armamentarium to prevent fatal hemorrhage recurrence with an acceptable low risk of procedural complications. Clinical outcomes depend mainly on the pre-procedural clinical state of the patient. Radiologic follow-up is necessary to prevent hemorrhage recurrence after EVT.

Endovascular versus Non-Interventional Therapy for Cervicocranial Artery Dissection in East Asian and Non-East Asian Patients: a Systematic Review and Meta-analysis

Endovascular methods have been increasingly applied in treating cervicocranial artery dissection (CCAD). Anti-thrombotic therapy, which is used in non-interventional care of CCAD patients, has differential effects in East Asian patients. Therefore, we aimed to compare the clinical outcomes of endovascular versus non-interventional therapy for CCAD in East Asians and non-East Asians. A search was performed for studies comparing endovascular and non-interventional approaches to CCAD patients. Rates of recovery, disability, and mortality were used to assess these approaches in East Asian and non-East Asian patients. Subgroup analyses were conducted for CCAD patients with ruptured dissections. Eleven East Asian studies and five non-East Asian studies were included. The subgroup analyses for CCAD patients with ruptured dissections on mortality (East Asian odds ratio [OR] [95% confidence interval [CI]]: 0.24 [0.08-0.71], P = 0.01; I² = 34%) and good recovery (East Asian OR [95% CI]: 3.79 [1.14-12.60], P = 0.03; I² = 54%) revealed that endovascular therapy is significantly superior to non-interventional therapy for East Asians. No differences in treatment effect upon mortality, disability, or good recovery outcomes were found for the CCAD populations-at-large nor for non-East Asian CCAD patients with ruptured dissections. Endovascular therapy appears to be superior to non-interventional therapy for East Asian CCAD patients with ruptured dissections.

Clinical features and prognosis of intracranial artery dissection

BACKGROUND

Intracranial artery dissections (IADs) are an important cause of stroke or subarachnoid hemorrhage (SAH). Outcome of IAD in the anterior circulation or presentation without SAH is rarely investigated and might be different.

OBJECTIVE

To evaluate the clinical features and prognosis of patients with IAD, with special emphasis on the location (anterior vs posterior circulation) and clinical presentation (SAH or cerebral ischemia).

METHODS

Between January 1998 and May 2012, 60 patients with IAD were included in this single-center cohort study. Clinical features, functional outcome, mortality, and prognostic factors were evaluated. Unfavorable functional outcome was defined as a modified Rankin scale score of 3 to 6.

RESULTS

In 18 patients (30%), IAD was located in the anterior circulation. At a median follow-up of 6.4 months, 35.3% of patients with IAD in the anterior circulation had an unfavorable functional outcome vs 39.0% in patients with IAD in the posterior circulation (P = .79). Forty-two patients (70%) presented with SAH. Clinical presentation with SAH was not significantly associated with poor functional outcome (41.5% vs 29.4%, P = .39). Low Glasgow Coma Scale score on admission (odds ratio, 0.72, P = .003) and older age (odds ratio, 1.04, P = .04) were independent predictors of unfavorable functional outcome. Mortality rate was 13% and did not significantly differ with location or clinical presentation.

CONCLUSION

Low Glasgow Coma Scale score on admission and older age were independent predictors of unfavorable functional outcome. IAD presenting with SAH was not significantly associated with poor functional outcome.

Natural history and management of basilar trunk artery aneurysms

BACKGROUND AND PURPOSE

Basilar trunk aneurysms (BTAs), defined as aneurysms distal to the basilar origin and proximal to the origin of the superior cerebellar artery, are rare and challenging to manage. We describe the natural history and management in a consecutive series of BTAs.

METHODS

Between 2000 and 2013, 2522 patients with 3238 aneurysms were referred to our institution for aneurysm management. A retrospective review of this database was conducted to identify all patients with BTAs.

RESULTS

In total, 52 patients had a BTA. Mean age was 56 (SD±18) years. Median clinical follow-up was 33 (interquartile range, 8-86) months, and imaging follow-up was 26 (interquartile range, 2-80.5) months. BTAs were classified into 4 causal subtypes: acute dissecting aneurysms, segmental fusiform ectasia, mural bleeding ectasia, and saccular aneurysms. Multiple aneurysms were more frequently noticed among the 13 saccular aneurysms when compared with overall population (P=0.021). There was preponderance of segmental ectasia or mural bleeding ectasia (P=0.045) in patients presenting with transit ischemic attack/stroke or mass effect. Six patients with segmental and 4 with mural bleeding ectasia demonstrated increasing size of their aneurysm, with 2 having subarachnoid hemorrhage caused by aneurysm rupture. None of the fusiform aneurysms that remained stable bled.

CONCLUSIONS

BTAs natural histories may differ depending on subtype of aneurysm. Saccular aneurysms likely represent an underlying predisposition to aneurysm development because more than half of these cases were associated with multiple intracranial aneurysms. Intervention should be considered in segmental ectasia and chronic dissecting aneurysms, which demonstrate increase in size over time as there is an increased risk of subarachnoid hemorrhage.

Stenting as monotherapy for uncoilable intracranial aneurysms

BACKGROUND

Small, blister-like aneurysms (BLAs), by virtue of their unique morphology, are difficult to treat with conventional modalities. The use of oversized self-expanding stents as monotherapy for BLAs is a relatively new and promising concept that warrants further investigation.

OBJECTIVE

To clarify the role of oversized self-expanding stents as monotherapy for BLAs.

METHODS

Five consecutive patients were treated for BLAs with oversized self-expanding stents alone by the senior author (K.R.B.). We report on their clinical and radiographic outcomes.

RESULTS

All 5 patients in our series were discharged in good clinical condition. Complete aneurysm occlusion was observed in all patients at the time of most recent radiographic follow-up. Mean follow-up time was 13.6 months (range, 1 month to 4.5 years).

CONCLUSION

The use of oversized self-expanding stents to redirect flow away from aneurysms is an effective option for patients with BLAs. This approach represents an alternative to the use of flow diverters.

Outcome of cervicocranial artery dissection with different treatments: a systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis is to compare clinical outcomes between endovascular treatment and conservative treatment for cervicocranial artery dissection.

METHODS

Medline, Embase, and Cochrane Library databases were searched for studies comparing endovascular treatment versus conservative treatment for cervicocranial artery dissection patients. The period searched was from November 1994 to March 2013. Fifteen observational studies involving 442 cervicocranial artery dissection patients were found. Evaluated outcomes included rate of mortality, disability, and good recovery. The rebleeding rate in subarachnoid hemorrhage (SAH) patients was also recorded and compared.

RESULTS

In general, patients who received endovascular treatment enjoyed a lower mortality rate than those who received conservative treatment (P = .02, odds ratio [OR]: .5, 95% confidence interval [CI]: .27-.90), especially patients having ruptured cervicocranial artery dissection (P = .002, OR: .32, 95% CI .15-.66) and dissecting aneurysms (P = .006, OR: .31, 95% CI .14-.71). Among SAH patients with a Hunt-Hess score of 3 or more, endovascular treatment decreased mortality significantly (P = .006, OR: .22, 95% CI .08-.65), whereas no significant differences between these 2 treatments occurred in patients having a Hunt-Hess score less than 3.

CONCLUSIONS

Endovascular treatment yields a better outcome, with greater benefit in patients with ruptured cervicocranial artery dissection, dissecting aneurysms, and a Hunt-Hess score of 3 or more. Randomized controlled trials comparing these 2 therapeutic strategies are needed.

Coiling occlusion of the vertebral artery for a patient with recurrent posterior circulation TIAs

Recurrent posterior circulation infarcts frequently involve multiple vascular territories, suggesting an embolic source. We describe a patient with left vertebral artery occlusion who had recurrent transient ischaemic attacks due to cerebral embolization originating from the occluded vertebral artery in spite of optimal anticoagulant and antithrombotic treatment. This was successfully managed by coiling occlusion of the vertebral artery with no recurrence of symptoms over one year of follow-up. To our knowledge, this is the first report of coiling occlusion in the treatment of recurrent vertebral artery embolization.

Reconstructive Treatment of Ruptured Intracranial Spontaneous Vertebral Artery Dissection Aneurysms: Long-Term Results and Predictors of Unfavorable Outcomes

Introduction

Few studies focused on predictors of unfavorable outcomes (modified Rankin Scale, 2–6) after reconstructive treatment of the ruptured intracranial spontaneous vertebral artery dissection aneurysms (ris-VADAs), which was evaluated based on 57 reconstructed lesions in this study.

Methods

Results of 57 consecutive patients (M:F = 29∶28; median age, 48 years; range, 27 to 69 years) harboring 57 ris-VADAs, which were treated with coils combined with single stent(n = 32), double overlapping stents (n = 16), and triple overlapping stents (n = 9) between October 2000 to March 2011, were retrospectively reviewed and analyzed.

Results

The available (n = 54) mean durations of angiographic and clinical follow-ups were 27 months (range, 12 to 78) and 62 months (range, 12 to 132), respectively. The involvement of PICA (p = 0.004), size of lesions (p = 0.000), quantity of stent (p = 0.001), and coil type (p = 0.002) affected the immediate obliteration grade, which was only risk factor for angiographic recurrences (p = 0.031). Although the post-treatment outcomes did not differ between single stent and multiple stents (p = 0.434), 5 angiographic recurrences, 1 rebleeding and 1 suspected rebleeding, all occurred in partial obliteration after single-stent-assisted coiling. Progressive thrombosis and in-stent obliteration were not detected on follow-up angiograms. Older age (odds ratio [OR] = 1.090; 95% confidence interval [CI], 1.004–1.184; p = 0.040) and unfavorable Hunt-Hess scale (OR = 4.289; 95%CI, 1.232–14.933; p = 0.022) were independent predictors of unfavorable outcomes in the reconstructed ris-VADAs.

Conclusions

Immediate obliteration grade was only risk factor for angiographic recurrence after reconstructive treatment. Unfavorable Hunt-Hess grade and older age were independent predictors of unfavorable outcomes in ris-VADAs.

Clinical characteristics of symptomatic vertebral artery dissection: a systematic review

BACKGROUND

Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed with adverse consequences. We assessed the frequency of head/neck pain, other neurological symptoms, and cerebrovascular events in symptomatic VAD.

METHODS

We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality, and clinical data were abstracted. Pooled proportions were calculated.

RESULTS

Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. The most common symptoms were dizziness/vertigo (58%), headache (51%), and neck pain (46%). Stroke was common (63%), especially with extracranial dissections (66% vs. 32%, P<0.0001), whereas transient ischemic attack (14%) and subarachnoid hemorrhage (10%) were uncommon. Subarachnoid hemorrhage was seen only with intracranial dissections (57% vs. 0%, P=0.003). Fewer than half of the patients had obvious trauma, and only 7.9% had a known connective tissue disease. Outcome was good (modified Rankin scale 0 to 1) in 67% and poor (modified Rankin scale 5 to 6) in 10% of patients.

CONCLUSIONS

VAD is associated with nonspecific symptoms such as dizziness, vertigo, headache, or neck pain. Ischemic stroke is the most common reported cerebrovascular complication. VAD should be considered in the diagnostic assessment of patients presenting with dizziness or craniocervical pain, even in the absence of other risk factors. Future studies should compare clinical findings as predictors in well-defined, undifferentiated populations of clinical VAD suspects.

Flow-diverting stent for ruptured intracranial dissecting aneurysm of vertebral artery

BACKGROUND

The treatment of ruptured dissecting aneurysms of the intracranial vertebral artery (VA) with parent vessel preservation is a challenge for neurosurgeons and interventional neuroradiologists.

OBJECTIVE

To propose an indication for flow-diverting treatment for reconstruction of a dissecting VA with acute subarachnoid hemorrhage.

METHODS

Two male patients transferred after acute subarachnoid hemorrhage and dissecting aneurysm on the V4 segment of the dominant VA. An occlusion test was not performed because of their poor clinical state. A flow-diverting stent represented by the Pipeline embolization device was suggested to both patients.

RESULTS

Three Pipeline embolization devices were deployed in each VA. One dissecting aneurysm was excluded immediately after 3 stents, and 1 patient had complete exclusion demonstrated at the 48-hour control. No morbidity directly related to the procedure was observed. No recanalization and no rebleeding occurred during the 3 months of follow-up.

CONCLUSION

A flow-diverting stent may be considered an option to treat ruptured dissecting aneurysms of the VA, providing remodeling of the parent vessel and complete exclusion of the aneurysm.

Subarachnoid hemorrhage due to vertebral artery dissection after lung resection

A 52-year-old man with massive hemoptysis underwent a left upper lobectomy. He suddenly reported a severe headache and lost consciousness on postoperative day 4. Computed tomography of the brain demonstrated a subarachnoid hemorrhage due to right vertebral artery dissection. Fortunately, he recovered well with intensive neurosurgical treatment. Vertebral artery dissection sometimes develops following systemic vascular disease, infection, and even minor neck trauma such as hyperextension or torsion of the neck. We should be aware that vertebral artery dissection may cause postoperative stroke and subarachnoid hemorrhage.

Intracranial dissection: incidence and long term endovascular treatment results of a not so rare disease

OBJECTIVE

The objective of this communication was to study the incidence and course of ICD and the long term outcome of this severe disease. The second goal was to analyze the different endovascular treatment modalities according to their long term results.

METHODS

It is a retrospective analysis of 14 patients with ICD admitted in a single center in two consecutive years, treated with endovascular procedures. Patients harbouring blister-like ruptured intracranial aneurysms were excluded from this study.

RESULTS

In this case series, 12 patients presented with subarachnoid hemorrhage (SAH) and 2 with brain stem symptoms. Mean age was 51 years and 13 patients were female. Six patients (43%) died and 8 (57%) survived with a mRS at 0-1. Mean follow up was 21 months.

CONCLUSIONS

ICD as a cause of SAH seems to be more frequent than previously thought and usually has a severe course. It requires a high level of suspicion to diagnosis and specific endovascular treatment modalities are required for each location to ensure long term stability and change the poor prognosis.

Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery

Object

Use of a flow-diverting device has shown promising short-term results in the management of vertebral artery (VA) dissecting aneurysms, but there is still uncertainty regarding its long-term efficacy and safety. The authors report their initial experience with respect to the potential utility and long-term clinical outcomes of using a flow-diverting device in the treatment of unruptured dissecting VA aneurysms.

Methods

The authors conducted a retrospective review of all cases of unruptured intracranial VA dissecting aneurysms treated at their institution (Tuen Mun Hospital) with a flow-diverting device. They describe the clinical presentations and angiographic features of the cases and report the clinical outcome (with modified Rankin Scale [mRS] scores) at most recent follow-up, as well as results of the latest angiographic assessment, with particular focus on in-stent patency and side-branch occlusion.

Results

A total of 4 aneurysms were successfully obliterated by using flow-diverting devices alone. Two devices were deployed in a telescoping fashion in each of 2 aneurysms, whereas only 1 device was inserted in each of the other 2 aneurysms. No periprocedural complication was encountered. No patient showed any angiographic evidence of recurrence, in-stent thrombosis, or side-branch occlusion in angiographic reassessment at a mean of 22 months after treatment (range 18–24 months). As of the most recent clinical follow-up (mean 30 months after treatment, range 24–37 months), all patients had favorable outcomes (mRS Score 0).

Conclusions

Reconstruction using a flow-diverting device is an attractive alternative in definitive treatment of dissecting VA aneurysms, demonstrating favorable long-term clinical and angiographic outcomes and the ability to maintain parent artery and side-branch patency. It is particularly useful in cases with eloquent side-branch or dominant VA involvement.

[Rebleeding from a vertebral artery dissection in a child: an inflammatory vasculopathy?]

We present a case of a rebleeding remote from a vertebral artery dissection associated with subarachnoid haemorrhage. A 7-year-old boy without any antecedent presented a traumatic dissection of the vertebral artery with subarachnoid haemorrhage. After a conservative treatment, the morphology of the vertebral artery became normal and the boy was asymptomatic. Four months later, a rebleeding occurred on the same vertebral artery, whose morphological review was normal. Mechanisms and cases of rebleeding in the literature are discussed. An inflammatory vasculopathy was suspected and discussed.

Management of ruptured and unruptured intracranial vertebral artery dissecting aneurysms

Vertebral artery dissecting aneurysms (VADA) are challenging disorders for neurosurgeons. Between December 2005 and May 2010, we treated 12 patients for DA of the intracranial VA. Three were treated by open surgery, seven underwent endovascular manipulation, and two were conservatively managed. Nine patients presented with subarachnoid hemorrhage from the ruptured aneurysm, and of these, two experienced abrupt re-hemorrhage and three presented with symptoms of brainstem ischemia. One of the two patients with a re-hemorrhage underwent conservative management and died in hospital of re-bleeding at 30 days after initial presentation. No postoperative neurological deficits occurred in patients treated by open surgery or via an endovascular approach. No re-hemorrhage or ischemic symptoms were observed in the 11 remaining patients during the mean 29-month (range: 14-54-month) follow-up. The chosen management strategy should be developed according to the patient's clinical condition and imaging results. Endovascular treatment, which includes several techniques, is the first choice for most patients.

Spontaneous intradural vertebral artery dissection: a single-center experience and review of the literature

OBJECTIVES

To define the natural history of spontaneous intracranial vertebral artery dissections (VADs) and to review current treatment strategies.

MATERIAL AND METHODS

We searched the MEDLINE database for all existing English and French literature on VADs through January 2008. Keywords employed were intradural/intracranial vertebral artery dissection, vertebral artery dissection, and vertebral artery dissection treatment. We also reviewed our series of patients with spontaneous VAD treated in the past 5 years. Data were collected, categorized, and analyzed.

RESULTS

In our sample of 457 patients, men were more frequently affected than women, and the mean age was 51.8 years. The majority of patients (79%) presented with subarachnoid hemorrhage (SAH). We experienced a high incidence (37%) of recurrent SAH, particularly within the first 24 hours after SAH first occurred. Angiographic fusiform dilatation and pearl-and-string lesions were the most common finding. Patients who presented with SAH fared worse than those who presented with ischemia.

CONCLUSIONS

Due to a high rate of recurrent bleeding, we concluded that early treatment by either surgical or endovascular route is indicated in patients who present with SAH secondary to spontaneous intradural VADs. Treatment decisions should take into account the site and type of dissection, vertebral artery dominance, and involvement of posterior inferior cerebellar artery.

Treatment of ruptured intracranial dissecting aneurysms in Hong Kong

Background:

Data suggests that hemorrhagic presentations occur in 20% of internal carotid artery dissections and 50% of vertebral artery dissections. A Finnish study has reported favorable outcomes in only 32% of patients.

We aimed to review the epidemiology and management outcomes in a Chinese population.

Methods:

We reviewed the aneurysmal subarachnoid hemorrhage registry of patients who presented with intracranial dissecting aneurysms at a neurosurgical center in Hong Kong over a five-year period.

Results:

A total of 23 patients with intracranial dissecting aneurysms were identified, accounting for 8% of all spontaneous subarachnoid hemorrhage patients. Forty-eight percent of the patients identified were treated by main trunk occlusion and 39% were treated by embolization or stent-assisted embolization or stent alone. Thirteen percent were managed by craniotomy and trapping or wrapping. Favorable outcomes at six months were achieved in 67%.

Conclusions:

Patients with intracranial dissecting aneurysms account for a significant proportion of the cases of spontaneous subarachnoid hemorrhage in our population. Carefully selected endovascular and microsurgical treatments can lead to management outcomes similar to patients with saccular aneurysms.

Pathomechanisms and treatment of pediatric aneurysms

Pediatric aneurysms are rare diseases distinct from classical adult aneurysms and therefore require different treatment strategies. Apart from saccular aneurysms that are more commonly found in older children, three major pathomechanisms may be encountered: trauma, infection, and dissection. The posterior circulation and more distal locations are more commonly encountered in children compared to adults, and there is an overall male predominance. Clinical findings are not only confined to subarachnoid hemorrhage but may also comprise mass effects, headaches or neurological deficits. In traumatic aneurysms, the skull base and distal anterior communicating artery are commonly affected, and the hemorrhage occurs often delayed (2-4 weeks following the initial trauma). Infectious aneurysms are mostly bacterial in origin, and hemorrhage occurs early after a septic embolic shower. Dissecting aneurysms are the most often encountered aneurysm type in children and can lead to mass effect, hemorrhage, or ischemia depending on the fate of the intramural hematoma. Treatment strategies in pediatric aneurysms include endosaccular coil treatment only for the "classical berry-type" aneurysms; in the other instances, parent vessel occlusion, flow reversal, surgical options, or a combined treatment with bypass and parent vessel occlusion have to be contemplated.

Symptomatic spontaneous vertebrobasilar dissections in children: review of 29 consecutive cases

OBJECT

The purpose of this study is to analyze the clinical presentation, morphological characteristics, angio-architecture, and outcome of vertebrobasilar dissection (VBD) in the pediatric population.

METHODS

The authors retrospectively reviewed 29 consecutive cases involving children younger than 16 years of age who were diagnosed with symptomatic VBDs. Data were gathered with respect to the patient's age, sex, clinical history, associated underlying disease, and symptoms (headache, vertigo) as well as the location of the dissection and the imaging appearance.

RESULTS

The patients' mean age was 8.24 years (range 2 months-15 years). There was an overall 3:1 male predominance, although among children older than 8 years, girls and boys were similarly affected. Hemorrhagic dissections occurred in 10 of 29 cases. In nonhemorrhagic dissections, stroke occurred in 16 cases, with the most common presenting symptoms being headaches and vertigo; in the other 3 cases, mass effect due to a chronic dissecting aneurysm was present. In 7 children an underlying vessel wall disease was found. The location of the dissection was extradural in 11 cases and intradural in the remainder. There was no preference with respect to side. The basilar artery was affected in 9 patients.

CONCLUSIONS

The imaging appearance and clinical presentation of symptomatic VBDs in the pediatric population differs from that in adults. Boys are more often affected, especially at younger ages, and hemorrhagic presentation is more common, presumably owing to the fact that the basilar artery is more commonly involved. Depending on the pathogenetic mechanism underlying the dissection, different clinical symptoms will evolve, necessitating individually tailored treatment.

The many faces of intracranial arterial dissections

Intracranial arterial dissecting diseases are rare and challenging diseases with a high associated morbidity and mortality. Their common pathomechanic origin is related to blood entering the vessel wall via an endothelial and intimal tear. Depending on the fate of the thus established intramural hematoma, different symptoms may ensue including mass effect, subarachnoid hemorrhage or ischemia. If the mural hematoma ruptures all vascular layers of the intradural artery, a subarachnoid hemorrhagic will occur. If the intramural hematoma reopens distally into the parent vessel on the other hand, ischemic embolic events may happen following intramural clot formation. If the mural hematoma does neither open itself into the parent vessel nor into the subarachnoid space, the vessel wall may dilate leading to occlusion of perforator branches and local ischemia. Organization of the mural hematoma may result in a chronic dissecting process which may eventually lead to formation of a "giant partially thrombosed" aneurysm with thrombus of varying ages within the vessel wall, ingrowth of vasa vasorum and recurrent dissections with subsequent growth of the aneurysm from the periphery. Treatment strategies of these diseases should take the underlying pathomechanism into consideration and include, depending on the presentation medical treatment, parent vessel occlusion, flow reversal or diversion, surgical options or a combined treatment protocol.

Intracranial vertebral artery dissection resulting in fatal subarachnoid hemorrhage: clinical and histopathological investigations from a medicolegal perspective

Object

Subarachnoid hemorrhage (SAH) due to a ruptured intracranial vertebral artery (VA) dissection sometimes results in a sudden fatal outcome. The authors analyzed the relationship between clinical features and histopathological characteristics among fatal cases to establish valuable information for clinical diagnostics and prophylaxis.

Methods

This study included 58 medicolegal autopsy cases of ruptured intracranial VA dissection among 553 fatal nontraumatic cases of SAH that occurred between January 2000 and December 2007. Their clinical features were obtained from autopsy records. Histopathological investigations were performed on cross-sections obtained from all 4-mm segments of whole bilateral intracranial VAs and prepared with H & E and elastica van Gieson staining.

Results

The autopsy cases included 47 males and 11 females, showing a marked predilection for males. The mean age was 46.8 ± 7.7 years, with 78% of the patients in their 40s or 50s. Hypertension was the most frequently encountered history; it was found in 36% of cases from clinical history and in 55% of cases based on autopsy findings. Prodromal symptoms related to intracranial VA dissections were detected in 43% of patients. Headache or neck pain lasting hours to weeks was a frequent complaint. Of patients with prodromal symptoms, 44% had consulted doctors; however, in none of these was SAH or intracranial VA dissection diagnosed at a preventable stage.

Autopsy revealed fusiform aneurysms with medial dissecting hematomas. Apart from ruptured intracranial VA dissection, previous intracranial VA dissection was detected in 25 cases (43%); among them, 10 showed previous dissection of the bilateral intracranial VAs. The incidence of prodromal symptoms (60%) among the patients with previous intracranial VA dissection was significantly higher than that (30%) among cases without previous dissection (chi-square test; p = 0.023). Most previous intracranial VA dissections formed a single lumen resembling nonspecific atherosclerotic lesions, with the exception of 3 cases (12%) with a double lumen.

Conclusions

Intracranial VA dissection resulting in fatal SAH frequently affects middle-aged men with untreated hypertension. Related to the high frequency of prodromal symptoms, latent previous intracranial VA dissection was histopathologically detected. Furthermore, intracranial VA dissection tends to induce multiple lesions affecting both intracranial VAs recurrently. This suggests the importance of an awareness of sustained whole intracranial VA vulnerability for the prevention of recurrence. The incidence of prodromal symptoms was significantly higher among patients with previous intracranial VA dissections. Thus, earlier diagnosis of intracranial VA dissections at the unruptured stage is desirable for prophylaxis against fatal SAH.

Traumatic vertebral artery dissection and Wallenberg syndrome after a motorcycle collision

Wallenberg syndrome is also called lateral medullary syndrome or posterior inferior cerebellar artery syndrome. The clinical presentations include ipsilateral Horner syndrome, ipsilateral cerebellar signs, and the hypalgesia of ipsilateral face and contralateral body. A considerable number of cases of Wallenberg syndrome were reported to be associated with vertebral artery dissection (VAD). Nowadays, the preferred imaging tool comes down to magnetic resonance imaging because it provides high spatial resolution, which is especially important for assessment of lesions in posterior fossa. The optimal treatment of VAD remains controversial. Most patients receive conservative treatments with anticoagulants or antiplatelet drugs. Overall, most cases have good prognosis. However, the rarity and various presentations of VAD may challenge emergency physicians in making correct diagnosis in the emergency department. Hence, maintaining a high index of suspicion is needed for an early diagnosis, especially in young people without risk factors attributing to cerebrovascular accident.

The aneurysmal wall. The key to a subclassification of intracranial arterial aneurysm vasculopathies?

SUMMARY

The pathogenesis of intracranial arterial aneurysms (AA) has been debated for many years and still remains unclear, although these entities might pose life-threatening risks to the patient and understanding the disease is of utmost importance for choosing treatment concepts. Apart from the "classical" berry-type aneurysm, there are different other types of intracranial AA such as infectious, dissecting or giant, partially thrombosed aneurysms. From the clinician's perspective, the hypothesis that some of these intracranial aneurysms might be due to abluminal factors has been put forward for many years. Alterations of the vessel wall, either due to luminal or abluminal factors may be employed for an etiological classification of aneurysmal vasculopathies as will be discussed in this article. Moreover, regarding certain aneurysmal vasculopathies as an abluminal disease might alter current therapeutic strategies since therapy should not only aim at the intraluminal repair of the artery but may also target the vessel wall.

Conservative treatment of ruptured vertebrobasilar dissecting aneurysm

Ruptured vertebrobasilar dissecting aneurysm is usually treated surgically because rebleeding negatively affects outcome. However, the risk of rebleeding decreases markedly once several hours have passed from the initial bleeding. Moreover, surgery-related complications are not rare. We describe seven patients with ruptured vertebrobasilar dissecting aneurysm. To prevent rebleeding during the acute stage, we treated all seven patients conservatively with fentanyl instead of emergency surgery. During the follow-up period (mean 20 months), no patient suffered rebleeding. Conservative treatment with fentanyl administration may be a good option for management of ruptured vertebrobasilar dissecting aneurysm during the acute stage.

Vertebral artery dissection: natural history, clinical features and therapeutic considerations

When a tear occurs in one of the major cervicocerebral arteries and allows blood to enter the wall of the artery and split its layers, the result is either stenosis or aneurysmal dilatation of the vessel. Vertebral artery dissection (VAD) is an infrequent occurrence but is a leading cause of stroke in young and otherwise healthy patients. This article discusses recent developments in understanding of the epidemiology and pathogenesis of VAD and the various clinical manifestations, methods of diagnosis, and approaches to treatment.

Cerebrovascular trauma

Vascular injury of the head and neck region is a rare and often life-threatening complication of head or neck trauma and is due to two major pathomechanisms: penetrating or blunt trauma. Both the arterial and the venous site of the CNS vasculature can be involved, the latter one being often overlooked. Concerning arterial lesions, depending on how many layers of the arterial vessel are affected and on the spatial relationship to adjacent structures, dissections, false aneurysms or arteriovenous fistulae may develop. On the venous side, dural tears, compressive effects on pial veins and a deranged clotting system may lead to delayed venous thrombosis. In this review we describe clinical and imaging findings, as well as diagnostic and treatment strategies in these lesions.