33 Treatment of Unruptured Vertebral Artery Dissecting Aneurysms Isao NAITO, M.D., Shin TAKATAMA, M.D., Naoko MIYAMOTO, M.D., Hidetoshi SHIMAGUCHI, M.D., and Tomoyuki IWAI, M.D. Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Japan Summary: We retrospectively investigated the clinical and angiographic follow-up results of intracranial vertebral artery (VA) dissection initially presented without subarachnoid hemorrhage (SAH) to clarify its management. Forty-one patients with VA dissection initially presenting without SAH were studied. Initial angiography revealed pearl and string sign in 18, double lumen sign in 4, aneurysmal dilatation with double lumen in 2, only aneurysmal dilatation in 6, occlusion in 7, and string-like stenosis in 4. Twenty patients, including 6 with subsequent SAH, underwent endovascular treatment (parent artery occlusion in 16 and stent-assisted coil embolization in 4). The other 21 patients were treated conservatively. The intervals between the onset and SAH were 1 day (2 patients), 3 days (2 patients), 14 days (1 patient) and 51 months (1 patient). One of the 16 patients treated by parent artery occlusion suffered from ischemic complications. Stentassisted coil embolization was safely performed in all of the 4 patients. Follow-up angiography of the 37 patients showed deterioration in 14, complete resolution or improvement in 9, and no change in 14. Thirty-seven patients achieved good recovery, and 4 patients remained moderately disabled due to the initial ischemic attack. Although the natural history of unruptured VA dissection is still unknown, endovascular treatment should be considered for patients with a relatively large or growing aneurysmal dilatation because prognosis of the patients with subsequent SAH is poor. Key words: endovascular treatment dissection vertebral artery Surg Cereb Stroke (Jpn) 33: 406413, 2005
Table 1 Angiographic findings and initial symptoms Angiographic finding Headache, Neck pain Infarction Pearl and string sign 12 (*5) 8 Aneurysmal dilatation 2 2 Aneurysmal dilatation with double lumen 1 1 Double lumen sign 1 3 String sign 3 1 Occlusion 2 5 ( 1) Total 21 ( 5) 20 ( 1) Asterisk indicates the patients with subsequent subarachnoid hemorrhage. Table 2 Angiographic findings and treatments Angiographic finding Conservative Endovascular Pearl and string sign 7 13 ( 5) Aneurysmal dilatation 3 1 Aneurysmal dilatation with double lumen 1 1 Double lumen sign 0 4 String sign 4 0 Occlusion 6 1 ( 1) Total 21 20 ( 6) Asterisk indicates the patients with subsequent subarachnoid hemorrhage.
Table 3 Chronological changes of angiographic features in 37 patients Initial angiographic finding No. of patients Follow-up angiographic finding No. of patients Pearl and string 16 complete resolution 1 (7m) reduction of aneurysmal dilatation 1 (5m) enlargement of aneurysmal dilatation 8 (10d, 14d, 15d, 16d, 17d, 36d, 24m, 88m) no change 6 (4d, 18d, 45d, 2m, 7m, 12m) Aneurysmal dilatation only 4 no change 4 (9d, 2m, 12m, 12m) Aneurysmal dilatation 2 reduction of aneurysmal dilatation 1 (6m) with double lumen enlargement of aneurysmal dilatation 1 (36m) Double lumen 4 progression of dissection 2 (9d, 23d) no change 2 (44d, 48d) String sign 4 complete resolution 2 (6m, 12m) occlusion 2 (13d, 22d) Occlusion 7 complete resolution 3 (9d, 5m, 17m) formation of aneurysmal dilatation 1 (51m) partial recanalization 1 (11m) no change 2 (18m, 24m) Angiographic follow-up period: 4 days-88 months (mean 9.0 months). d, days; m, months; underline indicating the patients treated with endovascular procedures.
Fig. 1 A 40-year-old man presented with sudden headache. A: CT scan on admission (3 days after the onset) showing no subarachnoid hemorrhage. B: MRA obtained on the same day showing a right vertebral dissecting aneurysm with pearl and string sign. C: This patient suffered from subarachnoid hemorrhage 1 hour after admission. D: Right vertebral angiogram showing a right vertebral dissecting aneurysm. E: A parent artery containing aneurysmal dilatation was embolized by using coils. A B C D E
Table 4 Summary of cases of unruptured vertebro-basilar artery dissection with subsequent SAH No. Authors & Year Age, Sex Timing of bleeding Initial angiographic finding Angiographic finding on SAH Treatment Outcome (reference No.) (days after onset) (GOS) 1 Takita., 33, M 3m normal (?) pearl and string none D 1979 (33) (bilateral vertebral arteries) 2 Yokoyama., 31, F 9d aneurysmal dilatation (1) none none D 1984 (36) 3 Okuchi., 13, M 2d none pearl and string proximal clipping MD 1990 (25) 4 Onda., 54, F 1m not described not described proximal clipping D 1994 (26) 5 Kawada., 58, M 4d aneurysmal dilatation not performed none D 1994 (9) with double lumen (0) 6 Funayama., 41, F 10d none not performed none D 1997 (4) 7 Sagoh., 62, M 11y pearl and string (?) pearl and string coating D 1997 (29) 8 Inagaki., 75, M 14d string sign (0) string sign proximal clipping MD 2000 (7) 9 Tsutsumi., 45, M 2d pearl and string (0) enlargement of proximal occlusion GR 2000 (34) aneurysmal dilatation with coil 10 Ogane., 32, F 12d none irregular dilatation none D 2000 (22) 11 Ono., 72, M 14d pearl and string (?) pearl and string none D 2001 (27) 12 Matsushige., 57, F 11d pearl and string (3) pearl and string proximal clipping GR 2001 (17) 13 Ogasawara., 45, M 12d pearl and string (5) occlusion proximal occlusion GR 2002 (23) with aneurysmal dilatation with coil 14 Koyama., 59, M 1d none pearl and string proximal occlusion GR 2002 (14) with coil 15 Oshiro., 46, M 4d aneurysmal dilatation (1) aneurysmal dilatation proximal occlusion GR 2003 (24) with coil 16 Yoshikawa., 66, M 29d irregular dilatation (0) irregular dilatation bilateral proximal occlusion D 2003 (37) with coil 17 Present Case 1 51, F 51m occlusion (3) occlusion with proximal occlusion GR 2002 (21) aneurysmal dilatations with coil 18 Present Case 2 42, M 1d none pearl and string proximal occlusion GR 2002 (21) with coil 19 Present Case 3 68, M 1d none pearl and string proximal occlusion GR 2002 (21) with coil 20 Present Case 4 44, M 3d none pearl and string proximal occlusion GR 2004 with coil 21 Present Case 5 60, M 14d none aneurysmal dilatation stent-assisted intraaneurysmal GR 2004 coil embolization 22 Present Case 6 40, M 3d pearl and string (day 3) pearl and string proximal occlusion GR 2004 with coil SAH, subarachnoid hemorrhage; GOS, Glasgow Outcome Scale; m, month(s); d, day(s); D, death; MD, moderate disability; GR, good recovery.
Fig. 2 A 64-year-old man presented with sudden headache and dysarthria. A: Left vertebral angiogram showing an aneurysmal dilatation with intimal flap. B: After insertion of a microcatheter into the aneurysm, a S670 stent measuring 3.5 mm 9 mm was deployed. C: The aneurysm was embolized by using coils. D: Left vertebral angiogram obtained after treatment showing the disappearance of the aneurysm with good patency of the parent artery. A B C D
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