PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of interneuroInterventional Neuroradiology
 
Interv Neuroradiol. 2016 April; 22(2): 138–142.
Published online 2015 December 18. doi:  10.1177/1591019915617325
PMCID: PMC4984341

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

Abstract

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.

Keywords: Subarachnoid hemorrhage, endovascular treatment, aneurysms

Introduction

Spontaneous bilateral vertebral artery dissections (VADs) are rare and account presumably for less than 10% of all vertebral artery dissections.13 Hemorrhagic dissections warrant early treatment given a high likelihood of re-rupture. If hemorrhages occur in the presence of bilateral VADs, bilateral deconstructive techniques such as proximal coil obliteration or internal trapping may not be possible because of insufficient collaterals from the anterior circulation. Unilateral occlusion only is in our opinion not indicated either, as the increased hemodynamic stress in the contralateral vertebral artery (VA) may lead to expansion or rupture of the untreated dissection,46 especially in cases where it is not possible to determine which site had ruptured. Although staged bilateral vertebral artery obliteration7 in the case of sufficient collateral flow from anterior circulation can be performed, interval hemorrhage or progressive aneurysm enlargement may occur. With the continued advances of stent technology, stent-related reconstructive techniques for ruptured or unruptured VADAs are emerging as a promising alternative to deconstructive techniques.810 In the following we present our treatment strategy for bilateral VADs in the context of acute subarachnoid hemorrhage (SAH) based on four patients, and we review the pertinent literature.

Methods

Patients

A retrospective review of our prospectively collected database on aneurysms was performed to identify all patients with acute SAH who harbored bilateral VADs in our institute between January 2000 and March 2012. A total of four consecutive patients (male:female = 2:2; mean age, 51.50 years; range, 38 to 58) harboring eight spontaneous VADAs (Hunt-Hess grade I in three, II in one) were identified and retrospectively analyzed. VADAs were diagnosed when angiographic imaging revealed fusiform or irregular dilation with or without stenosis in the vertebral artery. Based on the location of aneurysms relative to the posterior inferior cerebellar artery (PICA), the VADAs were classified as PICA-involving (n = 4) and not PICA-involving (n = 4) (see Table 1 for patient and aneurysm characteristics).

Table 1.
Clinical and radiographic characteristics of eight spontaneous intracranial VADAs presenting with SAH.

Treatment

As patients were referred to our institution from outside hospitals, time lag between SAH and treatment varied from two to 15 days. All patients received a loading dose of aspirin (300 mg) and Plavix (300 mg) administered orally or anally11 two hours before the procedure. All patients were heparinized during the procedure, and, after the procedure heparin was not reversed. In all cases, our strategy was to perform bilateral treatment during the same setting. If the rupture site could be identified without doubt based on cross-sectional and angiographical characteristics, we aimed to perform a deconstructive treatment of the dissected site followed by reconstructive treatment of the unruptured site (two patients). If the site of acute dissection could not be identified, bilateral reconstructive techniques were used (two patients).

A 6F guiding catheter (Envoy Max ID; Cordis, Johnson and Johnson Medical, Miami Lakes, FL, USA) was inserted into the VA inferior to the atlantal loop. For deconstructive treatment, the stent delivery catheter was placed at the portion distal to the dissection, and then the dissection was superselected using an Echelon10 microcatheter. After filling two to three coils, the stent was released (stents used were Neuroform (Boston Scientific, Natick, MA, USA), Enterprise (Cordis), and Solitaire™ AB (Covidien/ev3)). For patients who were scheduled to receive multiple stents, Enterprise stents were preferred. For patients who received destructive surgery, the Echelon10 was delivered to the dissection. For patients without PICA involvement, internal trapping with dense coil packing was performed (Case 1), and for patients with PICA involvement, proximal obliteration was performed (Case 2). After the procedure, aspirin (100 mg/d) and Plavix (75 mg/d) were administered for six weeks, after which Plavix was withdrawn.

Follow-ups

Angiographic follow-ups were scheduled at three to six months, then again at 12 months, and annually thereafter, this extensive follow-up was instigated as it was believed that patients with bilateral dissections may harbor an underlying vasculopathy that may make them more prone for dissections elsewhere. The immediate obliteration grades were categorized as complete obliteration (100%), near-complete obliteration (>90%, including residual dome or base), and partial obliteration (<90%),12,13 which was assessed independently by two authors (JML and WYZ), who have nine and 13 years of neurointerventional experience, respectively. Clinical outcomes were evaluated using the modified Rankin scale score (mRS), and results were classified into favorable outcomes (mRS, 0–1) and unfavorable outcomes (mRS, 2–6)14 on the basis of the most recent follow-up.

Results

Treatment

The clinical and radiological features of eight VADAs in the four patients are shown in the table. Six VADAs were reconstructed by coiling assisted with a single-stent (n = 3), coiling with multiple stents (n = 2) and stenting without coils (n = 1), while two VADAs were treated by deconstructive techniques with internal trapping or proximal obliteration, respectively. No procedure-related complication occurred.

Angiographic and clinical follow-ups

Complete obliteration was achieved immediately after treatment in three VADs. Near-complete obliteration was achieved in two VADAs immediately after reconstruction with one to three stent(s) and coiling, and transformed to complete obliteration in 20 minutes in Case 4 (Figure 1) and 50 minutes in Case 2 (Figure 2). Partial obliteration was achieved immediately after the procedure in the remaining three VADAs. Patients were followed up by cerebral angiography for a mean of eight (range 6–15) months with complete obliteration in all cases. There was no evidence of thrombosis, in-stent stenosis, or in-stent obliteration. The clinical follow-up period of the four patients averaged 63 (range 43–86) months and all patients had a favorable outcome (mRS 0–1). None of the patients had infarctions in the medulla or territory of the PICA.

Figure 1.
A patient with bilateral VADAs-involving PICA (Case 4) underwent reconstruction treatment using three stents with coiling (R) and two stents (L), respectively. The distribution of hemorrhage (a) and shape of two VADAs (b) indicated the possible ruptured ...
Figure 2.
A patient with bi-VADAs (Case 1) underwent endovascular treatment using three stents with coiling(R) and internal trapping (L), respectively. The right un-ruptured VADA-involving PICA (a) was first reconstructed with three stents and coiling (b), achieving ...

Discussion

Early treatment is recommended for ruptured VADAs, as the re-hemorrhage rate is 30%–71.4% and re-hemorrhage-related mortality is as high as 46.7%.15,16 Whether bilateral vertebral artery dissections fare even worse is, given the small number of reported cases, unclear. Considering the devastating consequence arising from VADA re-rupture, we employed single-stage endovascular treatment for all ruptured intracranial VADAs in this series, and its long-term results were evaluated based on four cases treated in our center over the course of the last 12 years.

Our strategy is to treat both lesions at the same time and employ deconstructive methods in cases we can identify the source of hemorrhage. In cases where we cannot identify the source of hemorrhage, we believe that bilateral reconstructive treatment is the treatment of choice to avoid increasing hemodynamic stress on a potentially untreated recently hemorrhaged lesion. However, this strategy is best within one month after SAH.

We do not think that open surgical intervention is an option for acute dissecting aneurysms of the vertebral artery given its rather high risks of treatment-related morbidity and mortality,3 thus most studies on treatment of these challenging conditions have employed endovascular therapies. Deconstructive endovascular treatments, including proximal obliteration and internal trapping, are established modalities for the treatment of unilateral intracranial VAD1719 but are limited for bilateral VAD by the degree of posterior communicating artery development.20,21 Deconstructive treatment modalities carry the risks of recurrence, ischemic events and re-bleeding, especially in cases of PICA involvement.22 A unilateral deconstructive treatment in bilateral dissections may furthermore increase expansion and rupture risk of the contralateral VADA, or may lead to the formation of a new dissection resulting from the effect of hemodynamic stress.23,24

Thus, several recent studies proposed reconstructive techniques, both employing stents (with and without additional coiling) and flow-diverting stents8,25,26 as a potential treatment option for intracranial dissecting diseases. The obvious risks associated with these types of treatment are related to the necessity to perform antiaggregation to prevent acute thrombembolic events. In our practice, we load the patients with aspirin and Plavix orally or anally two hours prior to a procedure and we contemplate external ventricular drain (EVD) placement prior to the intervention. The risk of acute re-hemorrhage after stent placement in dissecting aneurysms has been described; however, we believe that by adding coils and/or using multiple stents to increase the strut density over an acute dissection in order to “push the flap back” these events can be minimized.9,10 In addition, using multiple overlapping stents may straighten the curvature of the parent vessel, thus altering hemodynamic forces on the diseased vessel wall.27 Currently, the multiple stents technique is preferred at our center for VADAs; however, in the future, flow-diverting stents28,29 may represent a viable alternative for this type of treatment.

No postoperative re-hemorrhage occurred in our four patients and we demonstrated excellent long-term follow-up results—both from an angiographical and from a clinical point of view.

Nevertheless, a major limitation of this case series is the lack of large numbers. However, we think that our treatment strategy is a valid approach toward the management of these challenging lesions.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Natural Science Foundation of China (grant no. 81271271).

Conflict of interest

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

1. Greselle JF, Zenteno M, Kien P, et al. Spontaneous dissection of the vertebro-basilar system. A study of 18 cases (15 patients). J Neuroradiol 1987; 14: 115–123. [PubMed]
2. Tanaka K, Waga S, Kojima T, et al. Non-traumatic dissecting aneurysms of the intracranial vertebral artery. Report of six cases. Acta Neurochir (Wien) 1989; 100: 62–66. [PubMed]
3. Yamaura A, Watanabe Y, Saeki N. Dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 1990; 72: 183–188. [PubMed]
4. Yasui T, Sakamoto H, Kishi H, et al. Bilateral dissecting aneurysms of the vertebral arteries resulting in subarachnoid hemorrhage: Case report. Neurosurgery 1998; 42: 162–164. discussion 165. [PubMed]
5. Somekawa K, Nagata K, Kawamoto S, et al. Treatment for the ruptured bilateral vertebral dissecting aneurysms [article in Japanese]. No Shinkei Geka [Neurological Surgery] 2002; 30: 321–325. [PubMed]
6. Kim BM, Shin YS, Kim SH, et al. Incidence and risk factors of recurrence after endovascular treatment of intracranial vertebrobasilar dissecting aneurysms. Stroke 2011; 42: 2425–2430. [PubMed]
7. Sakamoto S, Ohba S, Shibukawa M, et al. Staged bilateral vertebral artery occlusion for ruptured dissecting aneurysms of the basilar artery: A report of 2 cases. Surg Neurol 2005; 64: 456–461. discussion 461. [PubMed]
8. Zhao KJ, Zhao R, Huang QH, et al. The interaction between stent(s) implantation, PICA involvement, and immediate occlusion degree affect symptomatic intracranial spontaneous vertebral artery dissection aneurysm (sis-VADA) recurrence after reconstructive treatment with stent(s)-assisted coiling. Eur Radiol 2014; 24: 2088–2096. [PMC free article] [PubMed]
9. Zhao KJ, Zhang YW, Xu Y, et al. Reconstruction of saccular and dissected intracranial aneurysms using Solitaire AB stents. PLoS One 2013; 8: e57253. [PMC free article] [PubMed]
10. Zhao KJ, Fang YB, Huang QH, et al. Reconstructive treatment of ruptured intracranial spontaneous vertebral artery dissection aneurysms: Long-term results and predictors of unfavorable outcomes. PLoS One 2013; 8: e67169. [PMC free article] [PubMed]
11. Zhao KJ, Yang PF, Huang QH, et al. Y-configuration stent placement (crossing and kissing) for endovascular treatment of wide-neck cerebral aneurysms located at 4 different bifurcation sites. AJNR Am J Neuroradiol 2012; 33: 1310–1316. [PubMed]
12. Suh SH, Kim BM, Park SI, et al. Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery. Clinical article. J Neurosurg 2009; 111: 48–52. [PubMed]
13. Wakhloo AK, Mandell J, Gounis MJ, et al. Stent-assisted reconstructive endovascular repair of cranial fusiform atherosclerotic and dissecting aneurysms: Long-term clinical and angiographic follow-up. Stroke 2008; 39: 3288–3296. [PubMed]
14. Kim BM, Kim SH, Kim DI, et al. Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection. Neurology 2011; 76: 1735–1741. [PubMed]
15. Mizutani T, Aruga T, Kirino T, et al. Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 1995; 36: 905–911. discussion 912–903. [PubMed]
16. Aoki N, Sakai T. Rebleeding from intracranial dissecting aneurysm in the vertebral artery. Stroke 1990; 21: 1628–1631. [PubMed]
17. Zhao WY, Krings T, Alvarez H, et al. Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: Review of 21 consecutive cases. Acta Neurochir (Wien) 2007; 149: 585–596. discussion 596. [PubMed]
18. Yamaura I, Tani E, Yokota M, et al. Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Guglielmi detachable coils. J Neurosurg 1999; 90: 853–856. [PubMed]
19. Peluso JP, van Rooij WJ, Sluzewski M, et al. Endovascular treatment of symptomatic intradural vertebral dissecting aneurysms. AJNR Am J Neuroradiol 2008; 29: 102–106. [PubMed]
20. Suzuyama K, Koizumi T, Udono H, et al. Staged bilateral VA embolization for SAH due to bilateral VA dissection: Case report [article in Japanese]. No Shinkei Geka [Neurological Surgery] 2002; 30: 1105–1108. [PubMed]
21. Redekop G, TerBrugge K, Willinsky R. Subarachnoid hemorrhage from vertebrobasilar dissecting aneurysm treated with staged bilateral vertebral artery occlusion: The importance of early follow-up angiography: Technical case report. Neurosurgery 1999; 45: 1258–1262. discussion 1262–1253. [PubMed]
22. Shin YS, Kim BM, Kim SH, et al. Endovascular treatment of bilateral intracranial vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage. Neurosurgery 2012; 70: 75–81. discussion 81. [PubMed]
23. Inui Y, Oiwa Y, Terada T, et al. De novo vertebral artery dissecting aneurysm after contralateral vertebral artery occlusion—two case reports. Neurol Med Chir (Tokyo) 2006; 46: 32–36. [PubMed]
24. Drapkin AJ, Rose WS. Serial development of ‘de novo’ aneurysms after carotid ligation: Case report. Surg Neurol 1992; 38: 302–308. [PubMed]
25. Shin YS, Kim HS, Kim SY. Stenting for vertebrobasilar dissection: A possible treatment option for nonhemorrhagic vertebrobasilar dissection. Neuroradiology 2007; 49: 149–156. [PubMed]
26. Zenteno MA, Santos-Franco JA, Freitas-Modenesi JM, et al. Use of the sole stenting technique for the management of aneurysms in the posterior circulation in a prospective series of 20 patients. J Neurosurg 2008; 108: 1104–1118. [PubMed]
27. Kim M, Levy EI, Meng H, et al. Quantification of hemodynamic changes induced by virtual placement of multiple stents across a wide-necked basilar trunk aneurysm. Neurosurgery 2007; 61: 1305–1312. discussion 1312–1313. [PMC free article] [PubMed]
28. Pereira VM, Bonnefous O, Ouared R, et al. A DSA-based method using contrast-motion estimation for the assessment of the intra-aneurysmal flow changes induced by flow-diverter stents. AJNR Am J Neuroradiol 2013; 34: 808–815. [PubMed]
29. Fischer S, Vajda Z, Aguilar Perez M, et al. Pipeline embolization device (PED) for neurovascular reconstruction: Initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology 2012; 54: 369–382. [PMC free article] [PubMed]

Articles from Interventional Neuroradiology are provided here courtesy of SAGE Publications