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Sun N, Yang XY, Zhao Y, Zhang QJ, Ma X, Wei ZN, Li MQ. Treatment of pediatric intracranial dissecting aneurysm with clipping and angioplasty, and next-generation sequencing analysis: A case report and literature review. World J Clin Cases 2021; 9:1103-1110. [PMID: 33644173 PMCID: PMC7896649 DOI: 10.12998/wjcc.v9.i5.1103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Large intracranial dissecting aneurysm (IDA) in the anterior cerebral circulation is rare in children. There has been no consensus on the diagnosis and treatment for IDA in children.
CASE SUMMARY We report a 3-year-old boy with a large ruptured IDA in the right middle cerebral artery (16 mm × 14 mm). The IDA was successfully managed with clipping and angioplasty. Next-generation sequencing of the blood sample followed by bioinformatics analysis suggested that the rs78977446 variant of the ADAMTS13 gene is a risk for pediatric IDA. Three years after surgery, the boy was develop-mentally normal.
CONCLUSION Clipping and angioplasty are effective treatments for ruptured IDA in the anterior cerebral circulation. ADAMTS13 rs78977446 is a risk factor for pediatric IDA.
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Affiliation(s)
- Ning Sun
- Department of Neurosurgery, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin 300134, China
| | - Xin-Yu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qing-Jiang Zhang
- Department of Neurosurgery, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin 300134, China
| | - Xiao Ma
- Department of Neurosurgery, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin 300134, China
| | - Zhong-Nan Wei
- Department of Neurosurgery, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin 300134, China
| | - Meng-Qi Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
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Zhang Y, Tian Z, Zhu W, Liu J, Wang Y, Wang K, Zhang Y, Yang X, Li W. Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10-year neurointerventional experience. Stroke Vasc Neurol 2020; 5:291-301. [PMID: 32792460 PMCID: PMC7548520 DOI: 10.1136/svn-2020-000376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/16/2020] [Accepted: 07/01/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The management of bilateral intracranial vertebral artery dissecting aneurysms (IVADAs) is controversial, and requires the development of endovascular treatment modalities and principles. We aim to investigate the endovascular treatment strategy and outcomes of bilateral IVADAs. METHODS We identified all bilateral IVADAs at a high-volume neurointerventional centre over a 10-year period (from January 2009 to December 2018). Radiographic and clinical data were recorded, and a treatment algorithm was derived. RESULTS Twenty-seven patients with bilateral IVADAs (54 IVADAs in total, 51 unruptured, 3 ruptured) were diagnosed. Four patients (14.8%) received single-stage endovascular treatment, 12 patients (44.4%) with staged endovascular treatment and 11 patients (40.8%) with unilateral endovascular treatment of bilateral IVADAs. Thirty-six IVADAs (85.7%) have complete obliteration at the follow-up angiography. Two of three ruptured IVADAs with stent-assisted coiling recanalised, and had further recoiling. Three patients (11.1%) have intraprocedural or postprocedural complications (two in single-stage and one in staged). Twenty-five patients (92.6%) had a favourable clinical outcome, and two patients (7.4%, all in single-stage) showed an unfavourable clinical outcome at follow-up. For the patients with unilateral reconstructive endovascular treatment, the contralateral untreated IVADAs were stable and had no growth or ruptured during follow-up period. None of all IVADAs had rebleeding during the clinical follow-up. CONCLUSIONS Endovascular treatment can be performed in bilateral IVADAs with high technical success, high complete obliteration rates and acceptable morbidity/mortality. Contralateral IVADAs had low rates of aneurysm growth and haemorrhage when treated in a staged/delayed fashion.
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Affiliation(s)
- Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Tsuji K, Watanabe A, Nakagawa N, Kato A. A case of unilateral vertebral artery dissection progressing in a short time period to bilateral vertebral artery dissection. Surg Neurol Int 2019; 10:126. [PMID: 31528462 PMCID: PMC6744788 DOI: 10.25259/sni-78-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/31/2019] [Indexed: 12/19/2022] Open
Abstract
Background Vertebral artery dissection (VAD) is an important cause of stroke in young and middle- aged people. Bilateral occurrence of VAD is generally considered rare, but the number of reports of bilateral VAD has been increasing in recent years. In this paper, we report a case of de novo VAD on the contralateral side presenting with subarachnoid hemorrhage in the acute stage of cerebral infarction due to unilateral VAD. Case Description A 52-year-old man developed sudden-onset left occipital headache, dizziness, dysphagia, and right-sided hemiparesthesia and was admitted to our hospital. Head magnetic resonance imaging on admission showed a left lateral medullary infarction due to the left VAD. At this point, the right vertebral artery was normal. However, on day 9 after onset, he suddenly presented with subarachnoid hemorrhage due to the right VAD. Emergency endovascular treatment was performed for the dissecting aneurysm of the right vertebral artery. The patient's condition improved gradually after the procedure, and he was discharged with a modified Rankin Scale score of 1. Conclusion Bilateral occurrence of VAD may be more common than previously believed. Even in cases of unilateral VAD, we need to pay attention to the occurrence of de novo VAD on the contralateral side.
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Affiliation(s)
- Kiyoshi Tsuji
- Departments of Neurosurgery, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, Japan
| | - Akira Watanabe
- Departments of Neurosurgery, Nara Hospital, Kindai University Faculty of Medicine, 1248-1 Otodacho, Ikoma, Nara, Japan
| | - Nobuhiro Nakagawa
- Departments of Neurosurgery, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, Japan
| | - Amami Kato
- Departments of Neurosurgery, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, Japan
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Ishikawa T, Yamaguchi K, Anami H, Ishiguro T, Matsuoka G, Kawamata T. Stent-assisted coil embolisation for bilateral vertebral artery dissecting aneurysms presenting with subarachnoid haemorrhage. Neuroradiol J 2016; 29:473-478. [PMID: 27558993 DOI: 10.1177/1971400916666559] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Bilateral dissecting aneurysms presenting with subarachnoid haemorrhage are rare. The treatment strategy for bilateral vertebral artery dissecting aneurysms is controversial because the contralateral vertebral artery is already dissected and can easily undergo enlargement or bleed after non-reconstructive treatment procedures such as trapping or proximal occlusion. Here, we report a case of bilateral vertebral artery dissecting aneurysm presenting with subarachnoid haemorrhage that was treated with stent-assisted coiling for the ruptured side. A 42-year-old man was admitted to our hospital with sudden headache (WFNS grade 1). Computed tomography showed a high-density region in the basal cistern and posterior fossa with more haemorrhage on the right side (Fisher group 3). Three-dimensional computed tomography and three-dimensional rotational angiography demonstrated a bilateral round protrusion on the vertebral arteries with a diameter of 5 mm just distal to the posterior inferior cerebellar artery. Stent-assisted coiling was performed for the ruptured right side and conservative therapy was selected for the contralateral side. The ruptured side was well embolised, and the contralateral side was stable over the 12-month follow-up period after treatment. The treatment strategy for bilateral vertebral artery dissecting aneurysms presenting with subarachnoid haemorrhage is different from that for unilateral vertebral artery dissecting aneurysms. Non-reconstructive treatment procedures such as trapping may cause contralateral enlargement or rupture; therefore, reconstructive treatment may be appropriate for the ruptured side.
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Affiliation(s)
- Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Hidenori Anami
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Taichi Ishiguro
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Go Matsuoka
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
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Shi L, Xu K, Sun X, Yu J. Therapeutic Progress in Treating Vertebral Dissecting Aneurysms Involving the Posterior Inferior Cerebellar Artery. Int J Med Sci 2016; 13:540-55. [PMID: 27429591 PMCID: PMC4946125 DOI: 10.7150/ijms.15233] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/01/2016] [Indexed: 12/04/2022] Open
Abstract
Among the variations of vertebral artery dissecting aneurysms (VDAs), VDAs involving the posterior inferior cerebellar artery (PICA), especially ruptured and high-risk unruptured aneurysms, are the most difficult to treat. Because the PICA is an important structure, serious symptoms may occur after its occlusion. Retained PICAs are prone to re-bleeding because VDAs are difficult to completely occlude. There is therefore confusion regarding the appropriate treatment for VDAs involving the PICA. Here, we used the PubMed database to review recent research concerning VDAs that involve the PICA, and we found that treatments for VDAs involving the PICA include (i) endovascular treatment involving the reconstruction of blood vessels and blood flow, (ii) occluding the aneurysm using an internal coil trapping or an assisted bypass, (iii) inducing reversed blood flow by occluding the proximal VDA or forming an assisted bypass, or (iv) the reconstruction of blood flow via a craniotomy. Although the above methods effectively treat VDAs involving the PICA, each method is associated with both a high degree of risk and specific advantages and disadvantages. The core problem when treating VDAs involving the PICA is to retain the PICA while occluding the aneurysm. Therefore, the method is generally selected on a case-by-case basis according to the characteristics of the aneurysm. In this study, we summarize the various current methods that are used to treat VDAs involving the PICA and provide schematic diagrams as our conclusion. Because there is no special field of research concerning VDAs involving the PICA, these cases are hidden within many multiple-cases studies. Therefore, this study does not review all relevant documents and may have some limitations. Thus, we have focused on the mainstream treatments for VDAs that involve the PICA.
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Affiliation(s)
- Lei Shi
- 1. Department of Neurosurgery, First Hospital of Jilin University, Changchun, China, 130021
| | - Kan Xu
- 1. Department of Neurosurgery, First Hospital of Jilin University, Changchun, China, 130021
| | - Xiaofeng Sun
- 2. Department of Ultrasonography, First Hospital of Jilin University, Changchun, China, 130021
| | - Jinlu Yu
- 1. Department of Neurosurgery, First Hospital of Jilin University, Changchun, China, 130021
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Zhao WY, Zhao KJ, Huang QH, Xu Y, Hong B, Liu JM. Single-stage endovascular treatment of subarachnoid hemorrhage related to bilateral vertebral artery dissecting aneurysms. Interv Neuroradiol 2015; 22:138-42. [PMID: 26686384 DOI: 10.1177/1591019915617325] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Treatment of bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage remains challenging as bilateral deconstructive procedures may not be feasible. In this case series, we describe our approach to their management and review the pertinent literature. METHOD A retrospective review of our prospectively collected database on aneurysms was performed to identify all patients with acute subarachnoid hemorrhage in the setting of bilateral intradural vertebral artery dissections (VAD) encompassing a period from January 2000 and March 2012. RESULT Four patients (M/F = 2/2; mean age, 51.5 years) were identified. In two cases the site of rupture could be identified by angiographic and cross-sectional features; in these patients deconstructive treatment (proximal obliteration or trapping) of the ruptured site and reconstructive treatment of the unruptured site (using stents and coils) were performed. In the patients in whom the site of hemorrhage could not be determined, bilateral reconstructive treatment was performed. No treatment-related complications were encountered. Modified Rankin scale scores were 0-1 at discharge, and on follow-up (mean 63 months), no recurrence, in-stent thrombosis or new neurological deficits were encountered. CONCLUSION We believe that single-stage treatment in patients with bilateral VAD is indicated: If the site of hemorrhage can be determined, we prefer deconstructive treatment on the affected site and reconstructive treatment on the non-affected site to prevent increased hemodynamic stress on the unruptured but diseased wall. If the site of dissection cannot be determined, we prefer bilateral reconstructive treatment to avoid increasing hemodynamic stress on the potentially untreated acute hemorrhagic dissection.
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Affiliation(s)
- Wen-Yuan Zhao
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Kai-Jun Zhao
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Qing-Hai Huang
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Yi Xu
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Bo Hong
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Jian-Min Liu
- Changhai Hospital, Second Military Medical University Shanghai, China
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Lim SH, Shin HS, Lee SH, Koh JS. Endovascular Treatment of Vertebral Artery Dissecting Aneurysms That Cause Subarachnoid Hemorrhage : Consideration of Therapeutic Approaches Relevant to the Angioarchitecture. J Korean Neurosurg Soc 2015; 58:175-83. [PMID: 26539258 PMCID: PMC4630346 DOI: 10.3340/jkns.2015.58.3.175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/10/2015] [Accepted: 07/20/2015] [Indexed: 12/28/2022] Open
Abstract
Objective Intracranial ruptured vertebral artery dissecting aneurysms (VADAns) are associated with high morbidity and mortality when left untreated due to the high likelihood of rebleeding. The present study aimed to establish an endovascular therapeutic strategy that focuses specifically on the angioarchitecture of ruptured VADAns. Methods Twenty-three patients with ruptured VADAn received endovascular treatment (EVT) over 7 years. The patient group included 14 women (60.9%) and 9 men (39.1%) between the ages of 39 and 72 years (mean age 54.2 years). Clinical data and radiologic findings were retrospectively analyzed. Results Four patients had aneurysms on the dominant vertebral artery. Fourteen (61%) aneurysms were located distal to the posterior inferior cerebellar artery (PICA). Six (26%) patients had an extracranial origin of the PICA on the ruptured VA, and 2 patients (9%) had bilateral VADAns. Eighteen patients (78%) were treated with internal coil trapping. Two patients (9%) required an adjunctive bypass procedure. Seven patients (30%) required stent-supported endovascular procedures. Two patients experienced intra-procedural rupture during EVT, one of which was associated with a focal medullary infarction. Two patients (9%) exhibited recanalization of the VADAn during follow-up, which required additional coiling. No recurrent hemorrhage was observed during the follow-up period. Conclusion EVT of ruptured VADAns based on angioarchitecture is a feasible and effective armamentarium to prevent fatal hemorrhage recurrence with an acceptable low risk of procedural complications. Clinical outcomes depend mainly on the pre-procedural clinical state of the patient. Radiologic follow-up is necessary to prevent hemorrhage recurrence after EVT.
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Affiliation(s)
- Seung Hoon Lim
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hee Sup Shin
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hwan Lee
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jun Seok Koh
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Chen YA, Qu RB, Bian YS, Zhu W, Zhang KP, Pang Q. Stent placement to treat ruptured vertebral dissecting aneurysms. Interv Neuroradiol 2013; 19:479-82. [PMID: 24355153 DOI: 10.1177/159101991301900412] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/24/2013] [Indexed: 11/17/2022] Open
Abstract
Conventional endovascular treatment may have limitations for vertebral dissecting aneurysm involving the origin of the posterior inferior cerebellar artery (PICA). We report our experiences of treating vertebral dissecting aneurysm with PICA origin involvement by placing a stent from the distal vertebral artery (VA) to the PICA to save the patency of the PICA. Stenting from the distal VA to the PICA was attempted to treat ruptured VA dissecting aneurysm involving the PICA origin with sufficient contralateral VA in eight patients. The procedure was successfully performed in seven patients with one failure because of PICA origin stenosis, which was treated with two overlapping stents. In the seven patients, PICAs had good patency on postoperative angiography and transient lateral brainstem ischemia represents a procedure-related complication. Follow-up angiographies were performed in seven patients and showed recanalization of the distal VA in three patients without evidence of aneurysmal filling. There was no evidence of aneurysm rupture during the follow-up period, and eight patients had favorable outcomes (mRS, 0 - 1). Placing a stent from the distal VA to the PICA with VA occlusion may present an alternative to conventional endovascular treatment for vertebral dissecting aneurysm with PICA origin involvement with sufficient contralateral VA.
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Affiliation(s)
- Yong-An Chen
- Department of Neurosurgery, Qilu Hospital, Shandong University; Jinan, China - Department of Neurosurgery, Yantai Yuhuangding Hospital, Qingdao University School of Medicine; Yantai, China -
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Lee DH, Yoon WK, Baik MW, Kim H. The difference of each angiographic finding after multiple stent according to stent type in bilateral vertebral artery dissection. J Cerebrovasc Endovasc Neurosurg 2013; 15:229-34. [PMID: 24167805 PMCID: PMC3804663 DOI: 10.7461/jcen.2013.15.3.229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/24/2013] [Accepted: 07/14/2013] [Indexed: 12/17/2022] Open
Abstract
We report a case of spontaneous bilateral intracranial vertebral artery dissecting aneurysms with subarachnoid hemorrhage. One dissecting lesion was treated with a coronary balloon-mounted stent (BMS) technique; however, due to differences in access route tortuosity, the other lesion was treated with a self-expandable stent (SES) technique. After 2 months, the angiographic outcome showed complete healing of the dissected segment on the side that was treated with BMS; in contrast, the dissection lesion appeared to be re-growing on the side that was treated with SES. Complete treatment of the aggravated lesion was achieved by additional deployment of BMSs. Therefore, we have provided a discussion of the possible reasons for this difference in outcome according to the stent type.
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Affiliation(s)
- Dong Hoon Lee
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Woon Ki Yoon
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Min Woo Baik
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Hoon Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
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Ali MS, Amenta PS, Starke RM, Jabbour PM, Gonzalez LF, Tjoumakaris SI, Flanders AE, Rosenwasser RH, Dumont AS. Intracranial vertebral artery dissections: evolving perspectives. Interv Neuroradiol 2012; 18:469-83. [PMID: 23217643 DOI: 10.1177/159101991201800414] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 08/25/2012] [Indexed: 11/16/2022] Open
Abstract
Intracranial vertebral artery dissection (VAD) represents the underlying etiology in a significant percentage of posterior circulation ischemic strokes and subarachnoid hemorrhages. These lesions are particularly challenging in their diagnosis, management, and in the prediction of long-term outcome. Advances in the understanding of underlying processes leading to dissection, as well as the evolution of modern imaging techniques are discussed. The data pertaining to medical management of intracranial VADs, with emphasis on anticoagulants and antiplatelet agents, is reviewed. Surgical intervention is discussed, including, the selection of operative candidates, open and endovascular procedures, and potential complications. The evolution of endovascular technology and techniques is highlighted.
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Affiliation(s)
- M S Ali
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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