Endovascular techniques for treating intracranial vertebral artery dissection-a single center experience

Document Type

Conference Proceeding

Publication Date

7-26-2021

Publication Title

J Neurointerv Surg

Abstract

Introduction Dissection of the intracranial segment (V4) of the vertebral artery (VAD) is a rare and serious condition. It can present either with ischemic symptoms related to stenosis, thrombosis or embolic phenomenon or with subarachnoid hemorrhage (SAH). Various endovascular techniques have been described for managing VAD. This study was conducted to review our institutional experience with patients with intracranial VAD who required endovascular intervention. Understanding clinical and treatment variables will yield preferred management options and guide our practice. Methods A retrospective, single-center study to review cases of intracranial vertebral artery dissection treated with endovascular intervention. Results A total of 20 patients with intracranial vertebral artery dissection were identified. Mean age (SD) was 50.8 (13.1), and M:F ratio was 1:1. Presentation was with SAH in 11 (55%) patients, ischemic symptoms in 4 (20%) patients and headache only in 5 (25%) patients. Dissection involved unilateral codominant VA in 10 cases, dominant artery in 2 cases, non-dominant artery in 3 cases and bilateral VAs in 5 cases. Angiographic anatomical review identified 11 VAD (55%) were distal to the PICA origin, 6 (30%) were at the origin of the PICA, and 3 (15%) were proximal to the PICA origin. Most common dissection etiology was spontaneous in 15 (75%) patients followed by fibromuscular dysplasia in 3 (15%) patients and traumatic in 2 (10%) patients. The treatment methods used were parent vessel coil occlusion in 12 (60%) cases, coil embolization of the aneurysm with vessel latency preservation in 5 (25%) cases and flow-diversion in 3 (15%) cases. Periprocedural complications were encountered in 3 cases with symptomatic ischemic symptoms in 2 cases and rebleeding in 1 case (early rerupture after flowdiversion). Median modified Rankin Scale (mRS) on discharge was 2 (0.5-3.5) and on 3 months follow up was 1 (0-2). Two cases of late aneurysmal recanalization were encountered and both cases in patient who were treated with aneurysmal coiling. There were 2 mortalities in the cohort. Both mortalities were due to withdrawal of care: one because of advanced age and the second was due to poor prognosis with massive brainstem infarction. Conclusion Endovascular treatment provides effective treatment for VAD. In our study, we demonstrated that sacrificing the parent artery with coil occlusion remains an effective and permeant treatment option for ruptured VAD. Risk of complications is low if the occlusion is distal to the origin of PICA as there is adequate collateral blood flow via ipsilateral AICA. Preservation of blood flow to the parent artery with stent assisted coiling or flow diversion stents provides alternative approach for treatment but in the setting of ruptured aneurysms, and the use of antithrombotic carries high rebleeding risk.

Volume

13

Issue

SUPPL 1

First Page

A80

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