A total of 20 males and 11 females were included, with a mean age of 47.0 years (range: 2 - 59 years). Patients who had dissecting aneurysms that involved the basilar artery, or in whom dissecting aneurysms not corresponding to the clinical symptoms were incidentally found, were also excluded. Patients who presented with clinical symptoms other than SAH, such as ischemic symptoms of posterior circulation, sudden onset of severe headache, or a combination of these, were excluded. All patients fulfilled the following inclusion criteria: 1) acute onset of subarachnoid hemorrhage (SAH) relevant to VADA, as confirmed by brain CT scan 2) angiographic findings of VADA, such as pearl-and-string sign, double lumen, beaded appearance of the parent artery, or fusiform dilatation with delayed clearance of the dilated lumen and 3) having undergone endovascular treatment for VADA. Between January 2010 and August 2014, 30 patients with ruptured VADAs underwent endovascular treatment at the two participating institutions. The institutional review boards of all participating hospitals approved this retrospective study and waived informed consent. The purpose of this retrospective study was to report the therapeutic efficacy, long-term imaging, and clinical follow-up results of various endovascular techniques that were performed on the basis of angiographic subtypes of ruptured VADAs, as well as the predictors of clinical outcomes. In addition, we monitored patients undergoing endovascular treatment over a period of one year, and assessed the clinical, angiographic, and procedural predictors of clinical outcomes. In this study, we performed a specifically selected mode of endovascular treatment for patients with ruptured VADAs, based on each patient’s clinical condition and the angiographic features of the dissected aneurysm.

Therefore, appropriate angiographic analysis of a ruptured VADA is an essential starting point from which to determine the optimal endovascular treatment method. Treatment strategies for a ruptured VADA should be individualized according to the severity of the presenting symptoms, the location of the dissected aneurysm in the parent artery with respect to the major perforating branches, and the adequacy of collateral supplies ( 4, 10- 12). However, the efficacy and long-term follow-up results of the various endovascular treatments have not been well established. In recent years, endovascular treatment has been the preferred first-line treatment method for ruptured VADA, and various endovascular techniques, including newer parent artery preservation techniques, have been introduced as possible treatment methods for this challenging condition ( 7- 9). Under these emergent circumstances, surgical interventions carry a relatively high risk of treatment-related morbidity and mortality ( 5, 6). Furthermore, most recurrent bleeding (ranging from 57% to 93%) occurs within 24 hours of the first hemorrhagic event, emphasizing the necessity of early and aggressive treatment ( 3, 4). Ruptured vertebral artery dissecting aneurysms (VADAs) are well-known for a high risk of recurrent bleeding and high mortality rates ( 1, 2). Stents Treatment Outcome Complications Surgery Aneurysm Embolization Retrospective Studies Vertebral Artery Dissection 1. However, under a limited set of conditions, SOT can be an effective alternative. ICT is a useful technique that completely eliminates the risk of rebleeding. Incomplete obliteration of a ruptured VADA using SAC was associated with a higher recurrence rate and fatal clinical outcomes. The preoperative neurologic status (represented by the world federation of neurosurgical societies grading) and immediate post-treatment angiographic results were confirmed as significant predictive factors of clinical outcomes (P =0.018 for both variables). No recurrence was observed in six patients treated with SOT, or among 16 patients with ICT. One patient with incomplete trapping for patency of the involved PICA experienced rebleeding. Two of the four patients with recurrence died. Of the seven patients treated with SAC, five showed partial obliteration and four experienced recurrence. Stent-assisted coiling (SAC) was performed in seven patients, stent-only therapy (SOT) was conducted for six patients, and the remaining 17 patients were treated with internal coil trapping (ICT). Of 25 aneurysms involving the non-dominant VA, 12 lesions showed involvement of the posterior inferior cerebellar artery (PICA), and one lesion’s origin was the anterior spinal artery. Dissecting aneurysms involving the dominant VA were found in five patients.

Pica artery dissection survival