Introduction: Internal coil trapping is the optimal treatment to prevent rebleeding from a ruptured intracranial vertebral artery dissection (VAD). The aim of this study is to determine the prognostic factors for a ruptured VAD and the clinical outcomes of the patients treated with internal coil trapping during the acute stage of a subarachnoid hemorrhage (SAH).
Methods: A retrospective review identified 38 patients, who presented from 2006 to 2011 with ruptured VADs and underwent internal coil trapping. When VAD involved the origin of the posterior inferior cerebellar artery (PICA), an occipital artery (OA)-PICA anastomosis was created prior to internal coil trapping. Pre- and postoperative radiological findings, clinical course and outcomes were analyzed.
Results: Internal coil trapping was completed within 24 hours after admission. The OA-PICA anastomosis was performed in 5 cases. Postoperative rebleeding did not occur in any of the cases. The clinical outcomes at 6 months were favorable (mRS 0-2) for 23 (60.5%) patients and unfavorable (mRS 3-6) for 15 (39.5%) patients. The logistic regression analysis predicted the following independent risk factors for unfavorable outcomes: postoperative medullary infarctions (odds ratio [OR] 21.287; 95% confidence interval [CI] 2.622-498.242; p=0.003); preoperative rebleeding episodes (OR 7.450; 95% CI 1.140-71.138; p=0.036); and a history of diabetes mellitus (OR 45.456; 95% CI 1.993-5287.595; p=0.013). High-grade SAH (WFNS grade 4/5) were not significant risk factor of unfavorable outcome (p=0.184). Postoperative MRIs showed medullary infarctions in 18 patients (47%). The mean length of the trapped VA for the infarction group (15.7 ± 6.0 mm) was significantly longer than that of the non-infarction group (11.5 ± 4.3 mm) (p=0.019).
Conclusions: Internal coil trapping for ruptured VADs is effective in preventing rebleeding. Even patients with high-grade SAH are candidates for internal coil trapping. A medullary infarction, which is associated with unfavorable outcomes, should be recognized as an ischemic complication of internal coil trapping.
Patient Care: The treatment selection of techniques such as deconstructive technique described in this paper or reconstructive technique using stent for each individual patient might represent a future treatment approach for ruptured VADs.
Learning Objectives: By the conclusion of this session, participants should be able to identify effectiveness of the internal coil trapping in preventing rebleeding from the ruptured vertebral artery dissection and clinical importance of its ischemic complication.