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

Spontaneous intracranial vertebral artery dissections presenting with subarachnoid hemorrhage

BACKGROUND

Vertebral artery dissection (VAD) is an infrequent source of subarachnoid hemorrhage (SAH), with a high mortality rate, primarily due to the risk of rebleeding both before and after medical intervention. This paper provides a comprehensive analysis of the anatomy, pathophysiology, clinical presentation, treatment strategies, and outcomes of intracranial vertebral artery dissections that result in subarachnoid hemorrhage.

METHODS

Comprehensive five-year literature review (2018-2022) and a retrospective analysis of patient records from our institution between 2016 and 2022. We included studies with a minimum of 5 patients.

RESULTS

The study incorporated ten series from the literature and 22 cases from CHUM. Key anatomical factors increasing the risk of VAD include the vertebral artery's origin from the aortic arch, asymmetry of the vertebral artery, and its tortuosity. Patients may display specific collagen and genetic abnormalities. The occurrence of VAD appears to be more prevalent in men. Those with a ruptured intracranial VAD typically show prodromal symptoms and present with severe SAH. Rebleeding within the first 24 h is frequent. While standard imaging methods are usually adequate for VAD diagnosis, they may not provide detailed information about the perforator anatomy. Treatment approaches include both deconstructive and reconstructive methods.

CONCLUSION

Ruptured VAD is a critical, life-threatening condition. Many patients have a poor neurological status at presentation, and rebleeding prior to treatment is a significant concern. Deconstructive techniques are most effective in preventing rebleeding, whereas the efficacy of reconstructive techniques needs more investigation.

Acute hemicranial pain accompanied with a pearl and string type dissection of intracranial vertebral artery: Consideration for the time when to finish the medical observation

The International Classification of Headache Disorder (ICHD) clearly guides the suspicion of intracranial vertebral artery dissection (ICVAD) in headache patients, but guidelines on how observational or imaging studies should be performed to detect dangerous progression early are unclear. Fifty-six cases with pearl and string type intracranial vertebral artery dissection were divided into 3 groups: 39 in the headache group, 6 in the infarction group, and 11 in the hemorrhagic group. Clinical and angiographic data were analyzed and compared. Most headaches resolved within 2 weeks and did not exceed 8 weeks. Of the 33 patients (84.6%) who underwent continuous follow-up imaging, 18 (54.5%) returned to normal, but 3 (9%) had deteriorated. All the patients survived without subsequent bleeding or infarction. Image changes started before 3rd month and ended after 6 to 7 months. In acute ICVADs, image changes occur at the same time as the headache resolves and continue for several months after the headache has subsided. Since the dissection is likely to worsen even after the headache disappears, the image changes continue over several months, and prediction of rupture of unruptured ICVAD is unpredictable, it is desirable to conduct continuous imaging studies regularly after the initiation of dissection until stabilization is confirmed.

Comparison of Parent Artery Occlusion and Stent-Assisted Treatments in Ruptured Vertebral Artery Dissecting Aneurysms

OBJECTIVE

To assess clinical outcomes of ruptured vertebral artery dissecting aneurysms, focusing on comparing parent artery occlusion (PAO) with stent-assisted treatments, and to identify risk factors for unfavorable outcomes and postprocedural complications.

METHODS

This retrospective review included 36 ruptured vertebral artery dissecting aneurysms treated between February 2009 and April 2020. Treatment modalities included PAO without stent and stent-assisted treatments. Stent-assisted treatments included PAO with posterior inferior cerebellar artery (PICA) stenting and stent-assisted coiling. Univariate and multivariate analyses were conducted to evaluate risk factors for unfavorable outcomes and postprocedural complications.

RESULTS

Patients were treated with PAO only (24, 66.7%), PAO with PICA stenting (4, 11.1%), and PAO with stent-assisted coiling (8, 22.2%). There were only fusiform aneurysms with PICA involvement in the PAO with PICA stenting group. In the stent-assisted coiling group, 4 aneurysms incorporated PICA, and 4 aneurysms involved dominant vertebral artery. Old age (odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.01-1.56, P = 0.044) and poor Hunt-Hess grade (OR = 537.99, 95% CI = 6.73-42994.1, P = 0.005) were significantly associated with unfavorable clinical outcomes after a mean follow-up of 37.5 ± 32.8 months. Fusiform dilatation shape (OR = 15.97, 95% CI = 1.52-167.38, P = 0.021) and PICA involvement (OR = 13.71, 95% CI = 1.29-145.89, P = 0.030) were independent risk factors for ischemic complications.

CONCLUSIONS

Unfavorable clinical outcomes were significantly related to old age and poor Hunt-Hess grade. There were no significant differences between treatment groups in clinical outcomes or ischemic complications. Stent-assisted treatments might be effective and safe methods for ruptured vertebral artery dissecting aneurysms.

Clinical and radiological risk factors for rupture of vertebral artery dissecting aneurysm: significance of the stagnation sign

OBJECTIVE

The aim of this study was to investigate the clinical and radiological factors associated with the rupture of a vertebral artery dissecting aneurysm (VADA) and to evaluate whether the stagnation sign is a significant risk factor for rupture of VADA.

METHODS

Clinical and radiological variables of 117 VADAs treated in a tertiary hospital from September 2008 to December 2020 were retrospectively reviewed. The stagnation sign is defined as the finding of contrast agent remaining in the lesion until the venous phase of angiography. Univariate and multivariate analyses were executed to reveal the associations between rupture status and VADA characteristics.

RESULTS

The rate of ruptured VADAs was 29.1% (34 of 117) and the stagnation sign was observed in 39.3% (46 of 117). Fusiform shape (OR 5.105, 95% CI 1.591-16.383, p = 0.006), irregular surface (OR 4.200, 95% CI 1.412-12.495, p = 0.010), posterior inferior cerebellar artery (PICA) involvement (OR 3.788, 95% CI 1.288-11.136, p = 0.016), and the stagnation sign (OR = 3.317, 95% CI 1.131-9.732, p = 0.029) were significantly related to rupture of VADA in multivariate logistic regression analysis.

CONCLUSIONS

This study showed that fusiform shape, irregular surface, PICA involvement, and the stagnation sign may be independent risk factors for the rupture of VADA. Therefore, when the potential risk factors are observed in unruptured VADA, more aggressive treatment rather than follow-up or medical therapy may be considered.

Symptomatic ischemic complications following endovascular treatment of vertebral artery dissecting aneurysms

PURPOSE

The aim of this study is to investigate the clinical and radiological features related to the symptomatic ischemic complications of vertebral artery dissecting aneurysm (VADA) following endovascular treatment (EVT).

METHODS

The clinical and radiological features of 127 VADAs, which were treated in a single tertiary institute between September 2008 and December 2020, were retrospectively reviewed. We defined a thrombosed aneurysm as being one which the thrombus was in the aneurysm in magnetic resonance imaging (MRI). Symptomatic ischemic complication was defined as a case in which acute infarction was confirmed on diffusion weighted image after EVT with associated clinical symptoms. Univariate and multivariate analyses were executed to demonstrate the associations between symptomatic ischemic complication and characteristics of VADA.

RESULTS

The rate of symptomatic ischemic complication was 13.4% (17 of 127). The thrombosed aneurysms were observed in 24.4% (31 of 127) and posterior inferior cerebellar artery (PICA) involvement was shown in 38.6% (49 of 127). Multivariate logistic regression analysis demonstrated that thrombosed aneurysms (odds ratio [OR] = 8.54, 95% confidence interval [CI] 1.98-36.87, p = 0.004) and PICA involvement (OR = 4.26, 95% CI 1.03-17.68, p = 0.046) were significantly associated with symptomatic ischemic complications following EVT.

CONCLUSION

This study showed that the VADAs with intra-aneurysmal thrombose and PICA involvement may be independent risk factors for symptomatic ischemic complications following EVT. Therefore, when the thrombosed VADAs with PICA involvement are observed, practitioners may consider close postoperative monitoring for early detection of ischemic complications.

Pipeline Embolization Device for the Treatment of Unruptured Intracranial Dissecting Aneurysms

Background: Intracranial dissecting aneurysms (IDAs) are rare but pose significant challenges to treatment. The pipeline embolization device (PED) has been demonstrated to be an effective treatment option with excellent outcomes. Herein, we report our experience with patients treated with the PED for unruptured IDAs.

Methods: We retrospectively reviewed our hospital database and identified patients who were treated with PEDs for unruptured IDAs between March 2016 and September 2020. Data including demographics, clinical presentation, aneurysm characteristics, procedural details, intra- or peri-procedural complications, and follow-up details were collected.

Results: Eighty patients (61 men, 76.25%) were treated with PED for unruptured IDAs. The most common symptoms were headache (34, 42.5%), dizziness (29, 36.25%), and nausea or vomiting (15, 18.75%). Of these patients, 73 had one aneurysm, and seven harbored two aneurysms. All of them achieved successful PED deployment. Six patients experienced intra- or peri-procedural complications including perforator artery occlusion, thromboembolic, hemorrhagic events, and falling of the stent into the aneurysm sac. Follow-up with digital subtractive angiography was available for 29 patients with a median of 6 months, and 28 (96.56%) patients had aneurysm occlusion. Late thrombosis occurred in four patients, and two of them had unfavorable outcomes. Clinical follow-up showed that a favorable clinical outcome was achieved in 76 (95%) patients, and the mortality rate was 3.75%.

Conclusion: Treating unruptured IDAs is safe and effective with long-term favorable clinical and angiographic outcomes. However, the complications of this treatment should be noted. Careful selection of appropriate patients and individualized antiplatelet therapy might be needed.

Comparison of Endovascular Treatments of Ruptured Dissecting Aneurysms of the Intracranial Internal Carotid Artery and Vertebral Artery with a Review of the Literature

Objective

Subarachnoid hemorrhage (SAH) caused by rupture of an internal carotid artery (ICA) or vertebral artery (VA) dissecting aneuryesm is rare. Various treatment strategies have been used for ruptured intracranial dissections. The purpose of this study is to compare the clinical and angiographic characteristics and outcomes of endovascular treatment for ruptured dissecting aneurysms of the intracranial ICA and VA.

Methods

The authors retrospectively reviewed a series of patients with SAH caused by ruptured intracranial ICA and VA dissecting aneurysms from March 2009 to April 2014. The relevant demographic and angiographic data were collected, categorized and analyzed with respect to the outcome.

Results

Fifteen patients were identified (6 ICAs and 9 VAs). The percentage of patients showing unfavorable initial clinical condition and a history of hypertension was higher in the VA group. The initial aneurysm detection rate and the percentage of fusiform aneurysms were higher in the VA group. In the ICA group, all patients were treated with double stent-assisted coiling, and showed favorable outcomes. In the VA group, 2 patients were treated with double stent-assisted coiling and 7 with endovascular trapping. Two patients died and 1 patient developed severe disability.

Conclusion

Clinically, grave initial clinical condition and hypertension were more frequent in the VA group. Angiographically, bleb-like aneurysms were more frequent in the ICA group and fusiform aneurysms were more frequent in the VA group. Endovascular treatment of these aneurysms is feasible and the result is acceptable in most instances.

Vertebral Artery Dissection: a Contemporary Perspective

Arterial dissections are among the most frequent causes of stroke in young adults. Usually they are associated with trauma, but as the modern imaging tools are evolving, more dissections are being diagnosed and more etiologies are being described. Vertebral artery dissections (VADs) have the distinct particularity that they can cause ischemic stroke (in the brainstem, cerebellum or even the spinal cord), but also subarachnoid hemorrhage, when the dissection occurs in the intracranial segment of the vertebral artery. We present a review of the literature, going over etiology, clinical aspects, diagnosis and treatment of VADs and we illustrate the theory with three different types of VAD from our clinical experience.

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.

Imaging investigation of intracranial arterial dissecting aneurysms by using 3 T high-resolution MRI and DSA: from the interventional neuroradiologists' view

OBJECTIVES

The purpose of this study was to investigate vessel wall imaging features combined with the luminal shapes of intracranial dissecting aneurysms (IDAs) by using 3 Tesla (3T) high-resolution magnetic resonance imaging (MRI) and digital subtraction angiography (DSA).

METHODS

Sixty-seven patients with 76 IDAs were consecutively enrolled in the study from December 2011 to May 2013. DSA was performed to diagnose an IDA and to categorize its angiography patterns into either aneurysmal dilation, steno-occlusive, combined, or unclassifiable. Images of 3T high-resolution MRI were used to evaluate arterial wall imaging features of each lesion. Chi-squared tests were used for statistical analyses.

RESULTS

Aneurysmal dilation (51 of 76, [67%]) was the most common angiography pattern of IDAs, followed by the combined pattern (20 of 76, [26%]). Seven percent (five of 76) of IDAs showed steno-occlusive (n = 3) and unclassifiable (n = 2) angiography patterns, in which intramural hematomas were detected in the arterial wall without luminal connection. Intimal flaps (32 of 76, [42%]), double-lumen sign (38 of 76, [50%]) and intramural hematomas (46 of 76, [61%]) were recognized as the characteristic features of dissection by high-resolution MRI. Intramural hematomas occurred more frequently in the combined patterns group (16 of 20, [80 %]) than in the aneurysmal dilation group (25 of 51, [49%]) (P = .017), while the occurrence of intimal flaps and double-lumen sign did not differ between angiographic patterns (P > .05).

CONCLUSIONS

3T high-resolution MRI combined with DSA offered clear visualization of vessel wall features and accurate assessment of the vessel lumen in IDAs. This combined approach would be highly useful for understanding the underlying pathological status of IDAs and in guiding treatment choices.

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.

Endovascular Treatment for Ischemic Stroke Induced by Vertebrobasilar Junction Artery Dissection

We reported 2 cases of vertebrobasilar junction artery dissection treated by different methods. Intra-artery thrombolysis was used to treat 1 patient, who died 53 hours after the procedure. The other case was treated by stenting for unaffected vertebral artery associated with a coil occlusion of affected vertebral artery, and the prognosis was good. These cases suggest that occlusion of proximal side of the vertebral artery affected by dissection and stenting for the junction between the other side of vertebral artery and the basilar artery may be a feasible method for vertebrobasilar junction artery dissection with or without thrombolysis.

Treatment of Spontaneous Intradural Vertebral Artery Dissections

Spontaneous intradural vertebral artery dissections may cause subarachnoid hemorrhage and often result in devastating damage. Increased use of noninvasive imaging studies has allowed larger numbers of patients to be diagnosed. In addition, intracranial vertebral artery dissection tends to induce multiple lesions affecting both intracranial vertebral arteries recurrently. Although unruptured dissections in this area usually have a benign nature, some authors have reported on the incidence of rupture from this lesion. Once hemorrhage from a dissecting vessel wall has occurred, it needs to be treated in the acute phase because of the high risk of rebleeding resulting in high morbidity and mortality. From December 2004 to July 2010, we managed 47 patients with spontaneous vertebral artery dissection, 31 patients were ruptured and 16 were unruptured. All patients who suffered from subarachnoid hemorrhage were treated with endovascular procedures. Most of the patients with unruptured dissection received medical therapy, but if the aneurysmal dilatation persisted or grew, surgical interventions were performed. Stenting with or without coils was deployed for 13 patients with posterior inferior cerebellar artery involvement at the site of dissection and/or were affected on the dominant side. In some patients, stenting was performed even if they were in the acute phase. For other ruptured patients, internal coil trappings were performed. Six patients died due to severe initial subarachnoid hemorrhage and one patient, who underwent stent deployment with coils for the dominant vertebral artery, with bilateral dissection continuing to the basilar artery died due to rerupture while the next additional coiling was planning. There were two cases of complications related to the intervention. During the follow-up period no bleeding occurred in any of the patients except for the previously mentioned patient. In conclusion, internal coil trapping or stent placement with or without coils was effective in preventing rebleeding of ruptured vertebral artery dissection. If the dissection is unruptured, it is necessary to detect the risk of bleeding with careful watching and when progress appears to be made, patients should be treated promptly. Stent-assisted therapy for preserving the patency of the parent artery and major branches is a promising treatment for vertebral artery dissection, even in the acute stage of subarachnoid hemorrhage. However, the risk of acute rerupture and recurrence remains even with the porous stent placement with or without coils.

Cerebral artery dissection: spectrum of clinical presentations related to angiographic findings

Purpose

Cerebral arterial dissections are recognized as a common cause of stroke. However, few studies have reported on the distribution of cerebral arterial dissection and angiographic pattern related to the presenting clinical symptom pattern. We analyzed the distribution of cerebral artery dissection along with angiographic and clinical presenting a pattern as depicted on angiograms.

Materials and Methods

From January 2000 to January 2007, 133 arterial dissection patients admitted to our institutes were retrospectively reviewed. The characteristic angiographic findings of all cerebral arteries were carefully evaluated on 4-vessel angiograms. The male-female ratio was 77: 56 and the mean age was 51 years. According to the angiographic finding depicting the location of the dissection plane in the arterial wall, we categorized to steno-occlusive, aneurysmal, combined and unclassifiable pattern. In each dissection pattern, we evaluated presenting symptoms and presence of infarction or hemorrhage.

Results

The most common symptom on presentation was headache (47%), followed by motor weakness of arm or leg (31%), dysarthria/aphasia (19%) and vertigo (16%). The most common angiographic pattern was steno-occlusive (46%), followed by combined (steno-occlusive and aneurismal) (27%) and aneurysmal (22%) patterns. Steno-occlusive pattern was most commonly related to infarction (33/61, 54%) in contrast that aneurysmal pattern was most frequently related to subarachnoid hemorrhage (SAH) (7/29, 24%). The most frequent abnormality in patients with dissection of the intradural vertebral arteries including posterior cerebral artery (PCA) was SAH (23/70, 33%), followed by infarction. Infarction was the most common abnormality in patients with the extradural and intradural carotid arteries, and the extradural vertebral artery.

Conclusion

In contrast that the extradural arterial dissections tended to result in ischemia with steno-occlusive pattern, the intradural arterial dissections tended to result in SAH with aneurysmal type, especially in the vertebral artery. Dissection requires combined analysis of angiographic pattern and type of stroke depending on the location.

Comparison of clinical characteristics and MR angiography appearance in patients with spontaneous intradural vertebral artery dissection with or without subarachnoid hemorrhage

Object

It is well known that spontaneous intradural vertebral artery dissection (siVAD) is an important cause of nontraumatic subarachnoid hemorrhage (SAH). The factors that influence whether SAH develops, however, remain unclear. The aim of this study was to investigate whether clinical characteristics and imaging findings are different in patients with siVAD with SAH compared to those with siVAD without SAH.

Methods

The authors conducted a retrospective, single-institution study involving patients in whom siVAD developed with or without SAH, between July 2003 and November 2010. Univariate and multivariate analyses were performed to evaluate clinical characteristics and MR angiography findings. The vertebral-union-basilar angle (VUBA) was defined as the most acute angle between line of the basilar artery trunk and line of the vertebral angle (VA) at the vertebral union on 3D MR angiograms.

Results

Among 58 patients with siVAD, 21 developed SAH. The presence of siVAD and SAH was significantly associated with higher rates of current smoking (OR 13; 95% CI 3.6–38; p < 0.0001), dissection of the dominant VA (OR 9.2; 95% CI 2.5–19; p = 0.0004), and unruptured supratentorial nondissecting saccular aneurysms (OR 11; 95% CI 2.1–19; p = 0.0025), and the VUBA of the dominant VA was significantly larger (p < 0.0001, univariate analysis). Multivariate analysis showed that these differences were still significant (p < 0.05).

Conclusions

A larger VUBA of the dominant VA, the presence of unruptured supratentorial nondissecting saccular aneurysms, and current smoking may be factors that predict which patients with siVAD will develop SAH by dominant VAD.