ENDOVASCULAR TREATMENT OF VERTEBRAL ARTERY DISSECTIONS AND PSEUDOANEURYSMS

Sixteen patients-with dissecting aneurysms or pseudoaneurysms of the v ertebral artery, 12 involving the intradural vertebral artery and four occurring in the extradural segment, were treated by endovascular occ lusion of the dissection site. Patients with vertebral fistulas were e xcluded from this study. The dissection was caused by trauma in three patients (two iatrogenic) and in the remaining 13 no obvious etiology was disclosed. Nine patients presented with subarachnoid hemorrhage (S AH), two of whom had severe cardiac disturbances secondary to the blee d. The nontraumatic dissections occurred in seven women and six men, w ith a mean age on discovery of 48 years. Fifteen patients were treated with endovascular occlusion of the parent artery at or just proximal to the dissection site. One patient had occlusion of a traumatic pseud oaneurysm with preservation of the parent artery. Four patients requir ed transluminal angioplasty because of severe vasospasm produced by th e presenting hemorrhage, and all benefited from this procedure with im proved arterial flow documented by transcranial Doppler ultrasonograph y and arteriography. In 15 patients angiography disclosed complete cur e of the dissection. One patient with a long dissection of extracrania l origin extending intracranially had proximal occlusion of the dissec tion site. Follow-up angiography demonstrated healing of the vertebral artery dissection but persistent filling of the artery above the ball oons, which underscores the need for embolic occlusion near the dissec tion site. No hemorrhages recurred. One patient had a second SAH at th e time of therapy which was immediately controlled with balloons and c oils. This patient and one other had minor neurological worsening resu lting from the procedure (mild Wallenberg syndrome in one and minor at axia in the second). Symptomatic vertebral artery dissections involvin g the intradural and extradural segments can be effectively managed by endovascular techniques. Balloon test occlusion and transluminal angi oplasty can be useful adjuncts in the management of this disease.