NATURAL HISTORY OF VERTEBROBASILAR DOLICHOECTASIA

Prospects and Dilemmas of Endovascular Treatment for Vertebrobasilar Dolichoectasia

Vertebrobasilar dolichoectasia (VBD) is characterized by significant expansion, elongation, and tortuosity of the basilar artery and vertebral artery. Certain highly selected cases of VBD can require intervention. Recent advances in endovascular treatment (EVT) have renewed hope for patients with VBD. However, which cases of VBD can benefit from EVT still needs to be determined. Currently, little is known regarding this matter. Therefore, we performed a review of the literature from a PubMed search and cataloged our experience regarding the classification and natural history of VBD and the prospects, prognosis and complications of EVT. The findings can be summarized as follows: for asymptomatic VBD, “wait and see” or medical management may be a reasonable strategy. EVT may only be effective in certain patients. For saccular aneurysms in VBD, especially ruptured aneurysms, EVT is reasonable. For fusiform aneurysms in VBD, EVT can carry high complication rates and should be recommended with caution. For stenting reconstruction in VBD, the effect is uncertain. For the future of EVT of VBD, randomized controlled trials and the development of neurointerventional products are worth pursuing, but EVT in VBD still has a long way to go.

Natural History of Vertebrobasilar Dolichoectatic and Fusiform Aneurysms: A Systematic Review and Meta-Analysis

Background and Purpose: Vertebrobasilar non-saccular and dolichoectatic aneurysms (VBDA) are a rare type of aneurysm and are generally associated with poor prognosis. In order to better characterize the natural history of VBDAs, we performed a systematic review and meta-analysis of the literature to determine rates of mortality, growth, rupture, ischemia, and intraparenchymal hemorrhage. Materials and Methods: We searched the literature for longitudinal natural history studies of VBDA patients reporting clinical and imaging outcomes. Studied outcomes included annualized rates of growth, rupture, ischemic stroke, intracerebral hemorrhage (ICH), and mortality. We also studied the association between aneurysm morphology (dolichoectatic versus fusiform) and natural history. Meta-analysis was performed using a random-effects model using summary statistics from included studies. Results: Fifteen studies with 827 patients and 5,093 patient-years were included. The overall annual mortality rate among patients with VBDAs was 13%/year (95% CI 8–19). Patients with fusiform aneurysms had a higher mortality rate than those with dolichoectatic aneurysms, but this did not reach statistical significance (12 vs. 8%, p = 0.11). The overall growth rate was 6%/year (95% CI 4–13). Patients with fusiform aneurysms had higher growth rates than those with dolichoectatic aneurysms (12 vs. 3%, p < 0.0001). The overall rupture rate was 3%/year (95% CI 1–5). Patients with fusiform aneurysms had higher rupture rates than those with dolichoectatic aneurysms (3 vs. 0%, p < 0.0001). The overall rate of ischemic stroke was 6%/year (95% CI 4–9). Patients with dolichoectatic aneurysms had higher ischemic stroke rates than those with fusiform aneurysms, but this did not reach statistical significance (8 vs. 4%, p = 0.13). The overall rate of ICH was 2%/year (95% CI 0–8) with no difference in rates between dolichoectatic and fusiform aneurysms (2 vs. 2%, p = 0.65). Conclusion: In general, the natural history of ­VBDAs is poor. However, dolichoectatic and fusiform ­VBDAs appear to have distinct natural histories with substantially higher growth and rupture associated with fusiform aneurysms. These findings suggest that these aneurysms should be considered separate entities. Further studies on the natural history of vertebrobasilar dolichoectatic and fusiform aneurysms with more complete follow-up are needed to better understand the risk factors for progression of these aneurysms.

Acute Bilateral Ophthalmoplegia Due to Vertebrobasilar Dolichoectasia: A Report of Two Cases

Case series

Patient: Male, 52 • Female, 68

Final Diagnosis: VBD

Symptoms: Ophthalmoplegia

Medication: —

Clinical Procedure: —

Specialty: Neurology

Imaging Characteristics of Growing and Ruptured Vertebrobasilar Non-Saccular and Dolichoectatic Aneurysms

Background and Purpose—

Vertebrobasilar, nonsaccular, and dolichoectatic aneurysms generally have a poor natural history. We performed a study examining the natural history of vertebrobasilar, nonsaccular, and dolichoectatic aneurysms receiving serial imaging and studied imaging characteristics associated with growth and rupture.

Methods—

We included all vertebrobasilar dolichoectatic, fusiform, and transitional aneurysms with serial imaging follow-up seen at our institution over a 15-year period. Two radiologists and a neurologist evaluated aneurysms for size, type, mural T1 signal, mural thrombus, daughter sac, mass effect, and tortuosity. Primary outcomes were aneurysm growth or rupture. Univariate analysis was performed with chi-squared tests for categorical variables and Student’s t test or analysis of variance for continuous variables. Multivariate logistic regression analysis was performed to identify variables independently associated with aneurysm growth or rupture.

Results—

One hundred and fifty-two patients with 542 patient-years (mean 3.6±3.5 years) of imaging follow-up were included. Aneurysms were fusiform in 45 cases (29.6%), dolichoectatic in 75 cases (49.3%), and transitional in 32 cases (21.1%). Thirty-five aneurysms (23.0%) grew (growth rate=6.5%/year). Eight aneurysms (5.3%) ruptured (rupture rate=1.5%/year). Variables associated with growth and rupture on univariate analysis were size >10 mm (57.6% versus 16.0%, P <0.0001), mural T1 signal (39.7% versus 16.3%, P =0.001), daughter sac (56.3% versus 21.3%), and mural thrombus (45.5% versus 13.4%, P <0.0001). 26.7% of fusiform aneurysms, 9.3% of dolichoectatic aneurysms, and 59.4% of transitional aneurysms grew or ruptured ( P <0.0001). The only variable independently associated with rupture was transitional morphology ( P =0.003).

Conclusions—

Vertebrobasilar, nonsaccular, and dolichoectatic aneurysms are associated with a poor natural history with high growth and rupture rates. Further research is needed to determine the best treatments for this disease.

Basilar artery dolichoectasia in childhood: evidence of vascular compromise

INTRODUCTION

Dolichoectasia describes the elongation, dilatation and tortuosity of an arterial vessel. In adults, clinical presentation of basilar dolichoectasia (BD) is most often with ischaemic stroke. True BD has been very rarely reported in childhood, but the implication is of a congenital susceptibility.

CASE REPORT

We describe two cases of infants with BD complicated by brainstem ischaemia.

DISCUSSION

This first description of childhood BD associated with ischaemic infarction adds to the understanding of this rarely reported arteriopathy.