| BACKGROUND:Intracranial dissecting aneurysm (IDA) is the special type of the aneurysm, it refers to a pathological dissection occurs in the arteries in the film between the membrane and the outer membrane or cause arterial wall prolapse, which can cause subarachnoid hemorrhage (SAH) and a series of symptoms. The annual incidence of vertebral artery dissection (VDA) is about 1.5/100 000 with dominant in males. Ischemic stroke caused by intracranial vertebral artery dissection accounts for only 2.5% of all ischemic stroke, but it accounts for 5% to 22% of young people under 45 years of ischemic stroke. It is also the second cause to atherosclerotic for ischemic young people. Once vertebral artery dissection bleed, it is prone to bleeding with rebleeding rate of 30%, what’s more, rebleeding mortality rate is more than 46%.Unruptured vertebral artery dissection clinical symptoms are not typical, often were overlooked by most people. Occipital headache sometimes is the initial performance, but lacks of specificity. Dizziness, vertigo, diplopia, ataxia and dysarthria caused by vertebrobasilar dissection are common clinical manifestations. Without timely treatment, the symptoms of posterior circulation ischemia will gradually aggravate and even increase the risk of the aneurysm rupture with irregular shape.So far, the treatment of unruptured vertebral artery dissection has no clear guidance strategy. Due to minor trauma, quicker recovery, limited surgical complications of the endovascular treatment, endovascular treatment gradually replaces surgery as the preferred method for treatment of vertebral artery dissection. Endovascular treatment is mainly including non-reconstruction surgery and reconstructive surgery. The former is used to occlude the parent artery or dissecting aneurysm, the latter mainly relies on the integrity of the lumen. Parent artery occlusion can prevent the blood from flowing into the tumor cavity, avoiding the aneurysm rupture. However, occlusion one side of the vertebral artery can lead to serious complications such as cerebral ischemia. As a revascularization technique stent-assisted coiling will change hemodynamic of the aneurysm, promote aneurysm thrombosis and spouting of the neointima along the stent struts can also lead to remodeling of the stented arterial segment. However, recurrence and bleeding complications remain the key factors affecting the efficacy of surgery.With the development of interventional techniques, interventional treatment continues to achieve good clinical results. However, due to the special anatomical structure, aneurysm recurrence is still a challenge to the physician involvement, directly affect the surgery, and further influence the quality of life of patients in the long-term fcllow-up. Compared to simple coiling embolization, stent-assisted coiling can significantly increase the degree of embolization, particularly stents overlap technique; flow diverting technique can largely reduce the recurrence rate aneurysms. However, due to the lack of large-scale clinical research, the recurrence rate is more difficult to estimate. With respect to the saccular aneurysm, dissecting aneurysm is also difficult to treat. Research about saccular aneurysm recurrence risk factors has been well studied, which including maximum diameter of the tumor, aneurysm neck width, and embolism rate, treatment methods. Dissecting aneurysm recurrence after embolization has been reported, but the exact mechanism is not fully understood, risk factors for aneurysm recurrence are scarcely studied. Correcting analysis of the impact of risk factors of recurrence, thus further reducing the rate of aneurysm recurrence, is particularly important for improving the prognosis of patients.This study collected a large number of vertebrobasilar aneurysms cases to explore the best treatment in the two above-mentioned methods. We also studied the patient’s basic information, medical history, clinical manifestations, imaging manifestations, treatment strategy, prognosis, by filtering and inclusion criteria to identify recurrence risk factors of the vertebrobasilar aneurysm, and further provided a theoretical reference for clinical treatment.Part 1 Endovascular treatment of unruptured vertebral dissecting aneurysmsOBJECTIVE:Discuss parent artery occlusion surgery and stent-assisted embolization of unruptured vertebral artery dissection effect. Analyzes the complication rate between two surgical methods, aneurysm recurrence rate, and provide guidance for clinical treatment.METHODS:We retrospectively reviewed 65 consecutive patients with unruptured vertebral dissecting aneurysms who underwent endovascular treatment between January 2004 and January 2014.24 patients underwent endovascular internal trapping (group A) while 41 patients underwent stent-assisted coiling (group B).13 patients underwent single stent with coiling while 28 patients underwent double or three stent-assisted coiling. Patient patient’s basic data collection, aneurysm characteristics, the incidence of postoperative ischemic, recurrence rate, (modified Rankin Scale, mRS) score were recorded. It was heparin after sheath using Seldinger femoral artery puncture success. First performed conventional angiography and three-dimensional reconstruction of the brain rotation angle selected the right job. Parent artery occlusion balloon occlusion surgery is not necessary during the procedure, but tests were conducted before and after the cross compensation cycle. Selected 6F guiding tube under fluoroscopy at the level of the neck 2, and then selected the microcatheter guidewire under the guidance of ultra-election into the aneurysm, implanted coils until aneurysms and parent artery occlusion were all occluded. For stent-assisted embolization, using half/full technology to release the stents. Preoperative and postoperative anticoagulation therapies were routinely administrated. Continuous variables were compared using unpaired t test or a Mann-Whitney U test, as appropriate. Categorical variables were compared using the Pearson’s chi-squared test, as appropriate. A p-value of less than 0.05 was considered statistically significant. Statistical analysis was performed using SPSS statistical software (SPSS 13.0 Chicago, IL, USA).RESULTS:Our study cohort had a marked male preponderance (34 males versus 31 females, age range 37 to 70 years, mean age 51.7 years). In group B,28 patients underwent double stent-assisted coiling; 13 patients underwent stent-assisted coiling alone. During the clinical follow-up period, in group A, two patients developed postoperative blurred vision, two patients developed dysphagia after 3 month, and MRI showed pontine infarction; one patient developed ataxia 2 months postoperatively without improvement in the follow-up period. In group B, one patient developed dizziness, and the symptom disappeared before discharge, there was no bleeding event during follow-up period. During the angiographic follow-up period, there were 3 recurrences, they were all initially received single stent-assisted coiling, and there was no recurrence in patients with multi-stent assisted coiling.During the follow-up period, there was no significant difference in mRS score between groups (1.2vs.0.79, P=0.24). Group A patients had more ischemia symptoms compared to group B patients (20.8% vs.5.3% P=0.043). Group B patients also trended towards higher recurrence rates compared with group A patients (7.3% vs.4.1 %) although this difference did not reach statistical significance (P=1.00). In group B, follow-up angiography demonstrated complete obliteration of 26 aneurysms, partial obliteration of 12 aneurysm, and recurrence in three aneurysms. Recurrence was found only in patients who underwent stent-assisted coiling alone (P=0.046).CONCLUSION:Internal trapping for unruptured vertebral dissecting aneurysms has a higher risk for ischemia. Stent-assisted coiling for unruptured vertebral dissecting aneurysms may maintain artery patency. Multilayer disposition of stents with coils may decrease the risk of recurrence and facilitate aneurysm occlusion.Part 2 Predictors of recurrence after stent-assisted treatment of intracranial vertebrobasilar dissecting aneurysmsOBJECTIVE:To investigate the risk factors for recurrence of vertebrobasilar dissection (Vertebrobasilar dissecting aneurysm VBDA) and the efficacy of stent-assisted embolization, provide a theoretical basis for clinical prevention and treatment of vertebrobasilar dissection.METHODS:We retrospectively reviewed 68 consecutive patients with vertebrobasilar dissecting aneurysms that underwent stent-assisted coiling from January 2006 to January 2014.41 patients underwent single stent with coiling while 27 patients underwent double or three stent-assisted coiling. Patient demographics, aneurysm characteristics, clinical manifestations, imaging, treatment methods, incidence of post-treatment recurrence, mRS score were recorded. It was heparin after sheath using Seldinger femoral artery puncture success. First performed conventional angiography and three-dimensional reconstruction of the brain rotation angle selected the right job. Parent artery occlusion balloon occlusion surgery is not necessary during the procedure, but tests were conducted before and after the cross compensation cycle. Selected 6F guiding tube under fluoroscopy at the level of the neck 2, and then selected the microcatheter guidewire under the guidance of ultra-election into the aneurysm, implanted coils until aneurysms and parent artery occlusion were all occluded. For stent-assisted embolization, using half/full technology to release the stents. Preoperative and postoperative anticoagulation therapies were routinely administrated. Continuous variable such as age was using a Mann-Whitney U test, as appropriate. Categorical variables were compared using the Pearson’s chi-squared test, as appropriate. All the variables for demonstrating significance in univariate analysis were entered into a multivariate logistic regression model to determine whether they remained independently associated with clinical outcomes. A p-value of less than 0.05 was considered statistically significant. Statistical analysis was performed using SPSS statistical software (SPSS13.0 Chicago, IL, USA).RESUITS:There were 43 men and 25 women (mean age 50.6 years, age ranged 7 to70 years),40 patients presented with SAH,10 with posterior headache of sudden onset,18 with dizzy. There were no procedure-related complications during the operation.41 patients underwent single stent with coiling while 27 patients underwent double or three stent-assisted coiling. Favorable outcomes (mRS 0-1) were obtained in 60 of 68 patients. Two patients who received single stent with coiling suffered from rebleeding. Post-treatment recurrence occurred in 8 patients,2 patients suffered from SAH.3 of 6 patients who diagnosed angiographic recurrence were treated by stent-assisted coiling.Univariate analysis showed that a higher rate of partial obliterate was observed in single-stent group. The immediate obliteration grade after initial treatment, posterior inferior cerebellar artery involvement, and single stent implantation were the risk factors for angiographic recurrence. Immediate obliteration grade (P=0.031) and posterior inferior cerebellar artery involvement (P=0.035) were the independent predictors of recurrence in the logistic regression analysis.CONCLUSION:Compared with single stent, multiple stents with coils may enhance the immediate obliteration grade and decreased the recurrence rate. Immediate obliteration grade and posterior inferior cerebellar artery involvement were the independent predictors for recurrence after reconstructive treatment of intracranial vertebrobasilar dissecting aneurysms. |
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