A Study of Vertebrobasilar Artery Dissection with Subarachnoid Hemorrhage

Abstract

We retrospectively studied clinical characteristics of 368 patients with cerebral artery dissections who were diagnosed in 172 Japanese hospitals. Of these patients, 130 (35%) presented with subarachnoid hemorrhage, 217 (59%) with cerebral infarctions, and 21 (6%) with transient ischemic attacks. We analyzed 109 (84%) subarachnoid hemorrhage cases caused by vertebrobasilar artery dissection to evaluate conservative and surgical treatment from the viewpoint of postoperative rerupture and infarction.Subsequent ruptures were observed in 14% of the 21 cases with nonsurgical treatment. For the preventive purpose of rerupture, 88 patients received surgical interventions: 68 trappings, 13 proximal occlusions, 6 aneurysmal sac occlusions and 1 stenting. Rerupture was experienced in 33% of the aneurysmal sac occlusion patients while not occurring in the other three surgical interventions. In the group without vascular anastomosis, postoperative cerebral infarction was observed in 25% of the trapping, none of the proximal occlusion and 33% of the aneurysmal sac occlusion cases.In this study, aneurysmal sac occlusion treatments were more frequently complicated by rerupture or cerebral infarction postoperatively than the other treatment methods. It was difficult to determine which surgical treatment can achieve better surgical outcome among the proximal occlusion and trapping with or without vascular anastomosis.

Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection

“…17 In a Mexican study 18 of 100 patients admitted to a neurology department for vertebral artery dissection with ischaemic stroke and without subarachnoid haemor rhage, 27 (27%) patients had intracranial artery dissection. In studies undertaken in east Asia, [19][20][21][22][23] in which patients were mostly recruited through neuro surgery and interventional neuroradiology departments, intracranial artery dissection Review accounted for up to 67-78% of all cervicocephalic artery dissections. 19,20 Most reported series of patients with intracranial artery dissection are from Asia (95% of studies including >40 patients with intracranial artery dissection, and 61% of studies including 20-39 patients with this disorder).…”

“…22 All treatment methods aim to reduce blood fl ow in the dissected region. Deconstructive techniques sacrifi ce the parent artery, whereas reconstructive techniques aim to maintain a parent artery.…”

“…21,41 Seldom, a bypass surgery between extracranial and intracranial arteries can be considered if the risk of infarction due to parent artery occlusion is unacceptably high and stenting is impossible. 22,42 In very rare instances, mostly in middle-cerebral artery dissections (M2 branches), the dissected segment can be excised and arterial stumps reanastomosed. 92 As for saccular intracranial aneurysms, endovascular treatment is currently more frequently undertaken than is surgical treatment in most patients with intracranial artery dissection with subarachnoid haemor rhage in scientifi c literature.…”

“…Recurrent bleeding was reported in 0-11% of patients with intracranial artery dissection with subarachnoid haemorrhage after surgical or endovascular treatment, and after treatment for ischaemia in 0-22% of patients. 19,[21][22][23][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] Cranial nerve palsies and spinal cord infarctions were seldom reported. 35,41,93 Overall, of 813 endovascular procedures, 50 (6•2%) cerebral or spinal cord ischaemia, 15 (1•8%) rupture and rebleeding, and seven (0•9%) cases of cranial nerve palsies were reported; of 125 surgical procedures, 23 (18•4%) cerebral or spinal cord ischaemia, one (0•8%) rupture and rebleeding, and one (0•8%) case of cranial nerve palsy were reported.…”

“…30 In patients with subarachnoid haemorrhage, recurrence of subarachnoid haemorrhage in up to 40% of patients has been reported, 30 with the highest rates being noted in patients treated conservatively. 22 Most haemorrhagic recurrences cluster within the days after the initial event. 22,30 In one study, 30 recurrent subarachnoid haemorrhage occurred more frequently in patients with intracranial artery dissection older than 50 years and less frequently in patients with carotid intracranial artery dissection.…”