Introduction: Spontaneous vertebral artery dissections account for 10% to 25% of strokes in those aged 25 to 45 years and intradural vertebral artery dissection aneurysms (VADA) are responsible for 5% of subarachnoid hemorrhages. Treating ruptured VADA is essential as these lesions have a high-risk of rebleeding with unfavorable outcomes. The purpose of this study was to report the clinical characteristics, radiologic findings, efficacy of endovascular treatment, and the predictors of outcome for patients with ruptured VADA.
Methods: Thirty-four consecutive patients with ruptured intracranial VADA treated via endovascular techniques at Auckland City Hospital between 1997 and 2013 were retrospectively reviewed from a prospectively maintained database.
Results: Of the 34 patients (mean age 48 years) treated, with a median Hunt and Hess Grade of 3 and median time to treatment of 3 days, hypertension and smoking were the most common risk factors associated with VADA; 59% and 47% respectively. Fifty-three percent of VADA occurred on the right with the pearl-and-string angiographic conformation in 73%. Methods of endovascular treatment included trapping (N=21), proximal occlusion (N=10), and reconstructive (N=1). Post-procedural VADA occlusion rate was 88% with a retreatment rate of 9%. Median follow-up was 29 months with a favorable modified Rankin scale (mRS) of less than or equal to 3 in 75%. Twenty-five percent of patients undergoing intervention had mRS greater than 3 at last follow-up with Hunt and Hess grade and major procedural complication demonstrating a correlation with unfavorable outcome; p=0.05 and p=0.01 respectively. Major complications included 4 failed interventions with infarction or increase in VADA size, 1 post-procedure clinically relevant embolic infarct, 1 post-procedure anterior spinal infarction, 1 peri-procedural death, and 1 iatrogenic dissection of contralateral vertebral artery.
Conclusions: Ruptured VADA are high-risk lesions that present with stereotypic characteristics. VADA can be managed safely and effectively by multimodal endovascular techniques with favorable outcomes.
Patient Care: This research will improve patient care by assisting medical professionals in identifying and counseling patients at risk for ruptured intracranial VADA.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Recognize the clinical presentation and radiographic findings associated with VADA, 2) Educate patients regarding the common risk factors associated VADA, 3) Identify the endovascular options for treating VADA, 4) Discuss the outcomes and complications related to endovascular treatment of VADA.