1994 Volume 22 Issue 1 Pages 41-46
To clarify the problems in the treatment of dissecting vertebral aneurysms (DVA), ten cases (six with SAH, four with brain stem infarction) were used for this study.
DVA was diagnosed by the typical vertebral angiographic findings of dissecting aneurysm. The posterior inferior cerebellar artery (PICA) was located at the proximal part of the DVA in six, distal in two and at the DVA in two cases. Six cases (four with SAH, two with infarction) underwent intravascular or direct surgery. Four cases (two with SAH, two with infarction) were conservatively treated. Proximal balloon occlusion of vertebral artery (VA) was performed in four cases, proximal VA ligation in one and trapping of DVA in one. After the proximal balloon occlusion, two cases needed additional direct surgery due to the residual or enlarged DVA. In both cases, proximal PICA had been spared at the side of the DVA. In the case of proximal VA ligation, late onset of brain stem infarction occurred, possibly due to the thrombosis of vertebro-basilar artery of the ligated side. The four conservatively treated cases enjoyed uneventful recoveries, and two of them showed angiographical spontaneous resolution of DVA.
Conclusion: Problems in the treatment of DVA are considered as follows. 1) Indication of intravascular or direct surgery: We treated the cases with SAH and obtained almost completely satisfactory results. However, angiographical natural resolution of DVA occurred in two cases. Since the natural history of DVA has not been elucidated, the indication of the treatment including the conservative treatment should be carefully evaluated. 2) Selection of treatment: We recommend an appropriate combination of intravascular and direct surgery. 3) Timing of the treatment: According to the reported papers, rebleeding occurred in the acute stage. However, surgical intervention in an acute stage is impractical because of the development of vasospasm. 4) Complication of the treatment: Thromboembolic complication after the proximal VA occlusion is a difficult problem that remains to be settled.
