- Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
George Kwok Chu Wong
Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
DOI:10.4103/2152-7806.74145© 2010 Wong GKC This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Chu Wong GK, Tang HB, Poon WS, Ho Yu SC. Treatment of ruptured intracranial dissecting aneurysms in Hong Kong. Surg Neurol Int 22-Dec-2010;1:84
How to cite this URL: Chu Wong GK, Tang HB, Poon WS, Ho Yu SC. Treatment of ruptured intracranial dissecting aneurysms in Hong Kong. Surg Neurol Int 22-Dec-2010;1:84. Available from: http://sni.wpengine.com/surgicalint_articles/treatment-of-ruptured-intracranial-dissecting-aneurysms-in-hong-kong/
Background:Data suggests that hemorrhagic presentations occur in 20% of internal carotid artery dissections and 50% of vertebral artery dissections. A Finnish study has reported favorable outcomes in only 32% of patients.
Methods:We reviewed the aneurysmal subarachnoid hemorrhage registry of patients who presented with intracranial dissecting aneurysms at a neurosurgical center in Hong Kong over a five-year period.
Results:A total of 23 patients with intracranial dissecting aneurysms were identified, accounting for 8% of all spontaneous subarachnoid hemorrhage patients. Forty-eight percent of the patients identified were treated by main trunk occlusion and 39% were treated by embolization or stent-assisted embolization or stent alone. Thirteen percent were managed by craniotomy and trapping or wrapping. Favorable outcomes at six months were achieved in 67%.
Conclusions:Patients with intracranial dissecting aneurysms account for a significant proportion of the cases of spontaneous subarachnoid hemorrhage in our population. Carefully selected endovascular and microsurgical treatments can lead to management outcomes similar to patients with saccular aneurysms.
Keywords: Cerebral aneurysm, dissection, embolization, stent, subarachnoid hemorrhage
The data suggests that hemorrhagic presentations occur in 20% of internal carotid artery dissections and 50% of vertebral artery dissections.[
In contrast to the high percentage of favorable outcomes in nonhemorrhagic patients, the Finnish study reported favorable outcomes in only a third of patients.[
We reviewed the aneurysmal subarachnoid hemorrhage registry of patients who presented with intracranial dissecting aneurysms at a neurosurgical center in Hong Kong over a five-year period. Because our institute introduced multi-slice computed tomographic angiography and flat panel biplane digital subtraction angiography five years ago, we decided to review the data for this five-year period. Patients were identified by reviewing the institutional database of aneurysmal subarachnoid hemorrhage patients.
The patient’s condition on admission was evaluated according to the Glasgow coma scale (GCS) and the world federation of neurological surgeons grading (WFNS). Patient histories were reviewed for hypertension, diabetes, medical history, and family history. Clinical outcomes were determined using a modified Rankin score (mRS), with favorable outcomes defined as 0-2. Follow-up angiographies were performed at six months and eighteen months to detect any signs of recurrence.
Endovascular treatment was chosen as the first option and was performed depending on the patient’s status,[
Statistical analysis was carried out using SPSS for Windows Version 15.0. A Fisher exact test and a Chi-square test were carried out as appropriate. Statistical significance was taken as P-value <0.05.
Twenty-three patients with intracranial dissecting aneurysms were identified over a five-year period [
Eleven (48%) patients were treated with main trunk occlusion through endovascular coiling; five (22%) patients were treated with embolization alone; two (9%) patients were treated with stent-assisted embolization; one patient had covered stent placement (JOSTENT, Abbott Vascular, Illinois); one patient was treated with a flow diverter (Pipeline Embolization Device [PED], eV3 Neurovascular, Irvine CA); and one patient had the aneurysm spontaneously thrombosed during embolization.
Three (13%) patients were treated with microsurgery. One patient was an 80-year-old woman who presented with WFNS Grade IV subarachnoid hemorrhage. An angiogram showed a 2 mm outpouch in the proximal middle cerebral artery. Because of the size of aneurysm, she received microsurgical exploration. Intraoperative findings confirmed dissection of the temporal branch of the middle cerebral artery, which was wrapped. She subsequently remained dependent. The other two patients had dorsal ophthalmic segment internal carotid artery blister aneurysms, for which one received surgical trapping and the other microsurgical clipping. They remained well on clinical follow up.
The follow-up period ranged from 1 to 53 months, with a mean of 28 months. Fourteen (67%) patients had a favorable neurological outcome. There were two (9%) deaths.
Two (9%) patients suffered from recurrent subarachnoid hemorrhage. One patient had proximal anterior cerebral artery dissecting aneurysm with coil embolization of the aneurysm together with anterior cerebral artery (main trunk occlusion). He developed recurrent hemorrhage presenting with decreased level of consciousness one month afterwards. An angiogram showed recanalization of the aneurysm, and a repeat embolization was performed. He subsequently remained dependent. Another patient had the dorsal ophthalmic segment internal carotid artery blister aneurysm spontaneously thrombosed during embolization. She suffered from recurrent hemorrhage with neurological deterioration two months afterwards and died during the same admission. Otherwise, there were no other recurrences detected during follow-up angiographies.
There were two (9%) procedural complications. One patient had a dissecting vertebral artery aneurysm just after the origin of the posterior inferior cerebellar artery. He received coil embolization of the aneurysm, together with main trunk occlusion of the vertebral artery, with the aim of preservation of flow to the posterior inferior cerebellar artery. However, sluggish flow to the posterior inferior cerebellar artery was noted at the end of the procedure. Intra-arterial abciximab (glycoprotein IIb/IIIa inhibitor) was given to restore flow to the posterior inferior cerebellar artery. He was then noted as having dilated pupils. Urgent computed tomography of the brain showed extensive midbrain hemorrhage and he subsequently died during the same admission. Another patient, who had covered stent insertion for the vertebral artery dissecting aneurysm between the origin of the posterior inferior cerebellar artery and the vertebrobasilar junction, developed cerebellar infract post-operatively. Total occlusion of the vertebral artery with sluggish flow to the posterior inferior cerebellar artery was found in the follow-up angiography.
A 49-year-old female presented to us after sudden collapse, with GCS 8/15. A CT brain scan showed extensive diffuse subarachnoid hemorrhage over the basal cisterns and hydrocephalus. She was intubated and an external ventricular drain was inserted to relieve the hydrocephalus. She had complications of neurogenic pulmonary edema and thrombocytopenia. Digital subtraction angiography on the next day showed features of dissecting aneurysm of the right vertebral artery, just after the origin of the posterior inferior cerebellar artery [Figure
(a) Simultaneous bilateral vertebral artery injections showing apparent occlusion of the right vertebral artery just distal to the origin of the posterior inferior cerebellar artery with a 2 mm remnant aneurysmal stump compatible with dissection; (b) Selective injection of the right vertebral artery showing a thin line of contrast passing the distal to the stump compatible with string sign; (c) Post-stent-assisted embolization DSA showing occlusion of the dissecting segment of the right vertebral artery with preservation of the posterior inferior cerebellar artery.
A 59-year-old female presented with sudden collapse, with GCS 5/15, to a local hospital while travelling. A CT brain scan showed diffuse subarachnoid hemorrhage over the basal cisterns. She recovered in the following two weeks and was transferred back to us for further management. Digital subtraction angiography showed a dominant left vertebral artery dissecting aneurysm distal to the origin of the posterior inferior cerebellar artery [
Because dissecting aneurysms have a pseudoaneurysm nature, direct microsurgical clipping is usually not feasible. Among the different causes of morbidity and mortality, or reasons for surgical failure, some authors suggest that thrombosis of the tiny perforating branches during surgical trapping contributes to the poor outcomes.[
A Pubmed review of treatments of hemorrhagic dissecting intracranial aneurysms, from January 2000 to December 2009, showed four case series that focused on stent alone treatment or stent-assisted embolization and one case series on covered stent.[
Theoretically, a covered stent graft for a segment without important branches is the simplest solution to the problem. The group from West China Hospital reported the application of covered stent grafts for five patients with hemorrhagic intracranial vertebral artery dissecting aneurysms.[
One limitation of the current study is the small sample size from a single neurosurgical center. Multi-center registry is useful to confirm the finding.
Dissecting intracranial aneurysms account for a significant proportion of the patients with spontaneous subarachnoid hemorrhage in our population. Carefully selected endovascular and microsurgical treatments can lead to management outcomes similar to patients with saccular aneurysms.
1. Ahn JY, Chung SS, Lee BH, Kim SH, Yoon PH, Joo JY. Treatment of spontaneous arterial dissections with stent placement for preservation of the parent artery. Acta Neurochir (Wien). 2005. 147: 265-73
2. Ahn JY, Han IB, Kim TG, Yoon PH, Lee YJ, Lee BH. Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling. Am J Neuroradiol. 2006. 27: 1514-20
3. Farrell M, Gilbert JJ, Kaufmann . Fatal intracranial arterial dissection: Clinical pathological correlation. J Neurol Neurosurg Psychiatry. 1985. 48: 111-21
4. He M, Zhang H, Lei D, Mao BY, You C, Xie XD. Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms. J Neurosurg. 2009. 110: 418-26
5. Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR. Curative endovascular reconstruction of cerebral aneurysms with the Pipeline Embolization Device: the Buenos Aires experience. Neurosurgery. 2009. 64: 632-43
6. Metso TM, Metso AJ, Helenius J, Haapaniemi E, Salonen O, Porras M. Prognosis and safety of anticoagulation in intracranial artery dissections in adults. Stroke. 2007. 38: 1837-42
7. Mizutani T, Kojima H, Asamoto S, Milky Y. Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms. J Neurosurg. 2001. 94: 712-7
8. Park SI, Kim BM, Kim DI, Shin YS, Suh SH, Chung EC. Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms. Am J Neuroradiol. 2009. 30: 1351-6
9. Rabinov JD, Hellinger FR, Morris PP, Oglivy CS, Putman CM. Endovascular management of vertebrobasilar dissecting aneurysms. Am J Neuroradiol. 2003. 24: 1421-8
10. Santos-Franco JA, Zenteno M, Lee A. Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options. Neurosurg Rev. 2008. 31: 131-40
11. Suh SH, Kim BM, Park SI, Kim DI, Shin YS, Kim EJ. Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery. J Neurosurg. 2009. 111: 48-52
12. Wakhloo AK, Mandell J, Gounis MJ, Brooks C, Linfante I, Winer J. Stent-assisted reconstructive endovascular repair of cranial fusiform atherosclerotic and dissecting aneurysms: Long-term clinical and angiographic follow-up. Stroke. 2008. 39: 3288-96
13. Yoon W, Seo JJ, Kim TS, Do HM, Jayaraman MV, Marks MP. Dissecting of the V4 segment of the vertebral artery: Clinicoradiological manifestations and endovascular treatment. Eur Radiol. 2007. 17: 983-93
14. Zhao WY, Krings T, Alvarez H, Ozanne A, Holmin S, Lasjaunias P. Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: Review of 21 consecutive cases. Acta Neurochir (Wien). 2007. 149: 585-96
15. Zweifler R, Weir B, Wolff PA.editorsStroke: Pathophysiology, diagnosis and management. Philadephia: Churchhill Livingstone; 2004. p.