Endovascular treatment of ruptured dissecting vertebral artery aneurysms-long-term follow-up results, benefits of early embolization, and predictors of outcome

Introduction: The purpose of this study was to evaluate the effect of endovascular treatment of ruptured dissecting aneurysms of the vertebral artery, the benefits of early embolization, and the predictors of outcomes. Clinical material and methods: Between September, 2001 and May, 2009, 25 patients with ruptured vertebral dissecting aneurysms were treated by internal coil trapping (n=23) or stents (n=2) in our hospital. There were 14 males and 11 females with a mean age of 45 years (age range, 22-66 years). Dissecting aneurysms were supra-posterior inferior cerebellar artery lesions (n=16), infra-posterior inferior cerebellar artery lesions (n=6), or involved the posterior inferior cerebellar artery (n=3). Results: Complete occlusion of dissected arterial and aneurysm segments (internal trapping) was achieved in 21 (91.3%) of 23 patients. The two patients with posterior inferior cerebellar artery involvement underwent double stent only placement. Clinical outcomes were favorable in 17 (68%) of 25 patients, 2 (8%) had severe disability, and 6 (24%) patients died. Risk factors that varied with favorable versus unfavorable outcomes were: preoperative Hunt-Hess, World Federation of Neurological Surgeons scale, presence of hydrocephalus, presence of lateral medullary syndrome, presence of low cranial nerve palsy, rebleeding, time of endovascular procedures, and time from admission to procedure. However, univariate Cox analysis confirmed that only low preoperative Hunt-Hess grade predicted favorable clinical outcome. Early embolization did not affect clinical outcome, but reduced the risk of rebleeding and inpatient stay. Conclusion: In our experience, internal trapping of the dissected segment with a coil was straightforward, applicable to most patients, prevented rebleeding safely and effectively without significant procedural complications, and had a good follow-up outcome. The low Hunt-Hess grade remained predictors of favorable clinical outcomes. The timing of embolization did not significantly affect clinical outcome but early embolization reduces inpatient stay.