INTRACRANIAL VERTEBRAL ARTERY DISSECTIONS - CLINICAL, RADIOLOGICAL FEATURES, AND SURGICAL CONSIDERATIONS

WE REVIEWED 24 patients with intracranial vertebral artery dissections treated during the last 12 years. Sixteen patients were admitted with subarachnoid hemorrhage (SAH) and 8 did not have SAH. The mean age at the time of onset was 50.0 years. Male preponderance was noted. Among 21 patients with acute onset, 6 (29%) experienced prodromal neck pain and 3 (60%) of 5 SAH patients showed nuchal stiffness when examined w ithin 6 hours of onset. The preoperative angiographical findings were uniform in SAH cases in contrast to the varied angiographical findings seen in non-SAH cases. So-called pearl and string sign was observed i n most SAH cases, but the ''string'' was often so short and wide that the term ''constriction'' appeared more suitable. From intraoperative observations, the angiographical point of constriction seemed to repre sent the proximal or distal end of dissection. As for treatment, 19 pa tients underwent 20 surgeries. Trapping was performed in eight surgeri es, base clipping was performed in five, and proximal clipping was per formed in seven. Both trapping and base clipping prevented further ble eding, but trapping was associated with a high rate of postoperative l ower cranial nerve palsy. Postoperative neurological complications wer e less frequent after proximal clipping, but subsequent postoperative bleeding occurred in one patient treated by this technique. The overal l long-term outcome in the surgically treated cases in our series was favorable, but most patients suffered from various degrees of uncomfor table dysphagia or hoarseness for some period after surgery. It was al so noted that, in half of the disabled cases, the major disability was attributable to lower cranial nerve palsy and respiratory troubles th at developed postoperatively.