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Clinical outcomes of patients with vertebral artery dissection treated endovascularly: a meta-analysis

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Abstract

The purpose of this study was to present a meta-analysis on the safety and efficacy of different endovascular modalities when treating vertebral artery dissections, since ideal treatment remains controversial. We performed a meta-analysis of 39 retrospective studies involving different treatment modalities for vertebral artery dissections in adults and obtained weighted pooled proportional outcome and mortality ratios with a random effects model. Overall, 75.11 % (confidence interval (CI) 68.89–80.84, I 2 66.89 %) had excellent outcomes, 10.10 % (CI 6.83–15.56, I 2 65.64 %) had good outcomes, and 13.70 % (CI 9.64–18.35, I 2 60.33 %) had poor outcomes. Postoperative complications occurred in 10.52 % (CI 6.87–14.84, I 2 62.48 %), with 2.73 % (CI 1.64–4.10, I 2 0.0 %) exhibiting vasospasm, 3.03 % (CI 1.88–4.46, I 2 0.0 %) experiencing postoperative rebleeding, and 6.31 % (CI 3.57–9.76, I 2 60.92 %) showing ischemia. Overall mortality was 8.69 % (CI 6.13–11.64, I 2 33.76 %). When compared to these overall ratios, different treatment modality subgroups did not differ significantly, except for the proximal occlusion group, with poor outcome ratio = 26.96 % (difference 13.26, CI 0.02–30.04, p = 0.0403) and mortality ratio = 21.36 % (difference 12.67, CI 0.94–28.86, p = 0.0189). Different endovascular treatment modalities are comparatively safe and effective in the management of vertebral artery dissection. Their reduced operative time, minimal invasiveness, and overall safety render them a suitable option for intervention-amenable dissections.

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References

  1. Ahn J, Chung S, Lee B, Kim S, Yoon P, Joo J et al (2005) Treatment of spontaneous arterial dissections with stent placement for preservation of the parent artery. Acta Neurochir 147:265–273

    Article  PubMed  CAS  Google Scholar 

  2. Ahn J, Han I, Kim T, Yoon P, Lee Y, Lee B et al (2006) Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling. AJNR 27:1514–1521

    PubMed  CAS  Google Scholar 

  3. Albuquerque F, Fiorella D, Han P, Deshmukh V, Kim L, McDougall C (2005) Endovascular management of intracranial vertebral artery dissecting aneurysms. Neurosurg Focus 18:E3

    PubMed  Google Scholar 

  4. Ali M, Amenta P, Starke R, Jabbour P, Gonzalez L, Tjoumakaris S et al (2012) Intracranial vertebral artery dissections: evolving perspectives. Interv Neuroradiol 18:469–483

    PubMed  CAS  PubMed Central  Google Scholar 

  5. Ansari S, Thompson B, Gemmete J, Gandhi D (2008) Endovascular treatment of distal cervical and intracranial dissections with the neuroform stent. Neurosurgery 62:636–646

    Article  PubMed  Google Scholar 

  6. Anxionnat R, Ferreira de Melo-Neto J, Bracard S, Lacour J, Pinelli C, Civit T et al (2003) Treatment of hemorrhagic intracranial dissections. Neurosurgery 53:289–301

    Article  PubMed  Google Scholar 

  7. Brandt T, Morcher M, Hausser I (2005) Association of cervical artery dissection with connective tissue abnormalities in skin and arteries. Front Neurol Neurosci 20:16–29

    Article  PubMed  CAS  Google Scholar 

  8. Brandt T, Orberk E, Weber R, Werner I, Busse O, Müller B et al (2001) Pathogenesis of cervical artery dissections: association with connective tissue abnormalities. Neurology 57:24–30

    Article  PubMed  CAS  Google Scholar 

  9. Brott T, Halperin J, Abbara S, Bacharach J, Barr J, Bush R et al (2011) 2011 ASA/ACCF/AHA/AAN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. J Neuro Interv Surg 3:100–130

    Google Scholar 

  10. Chandra A, Suliman A, Angle N (2007) Spontaneous dissection of the carotid and vertebral arteries: the 10-year UCSD Experience. Ann Vasc Surg 21:178–185

    Article  PubMed  Google Scholar 

  11. Endo H, Matsumoto Y, Kondo R, Sato K, Fujimura M, Inoue T et al (2013) Medullary infarction as a poor prognostic factor after internal coil trapping of a ruptured vertebral artery dissection. J Neurosurg 118:131–139

    Article  PubMed  Google Scholar 

  12. Flis C, Jäger H, Sidhu P (2007) Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol 17:820–834

    Article  PubMed  Google Scholar 

  13. Fusco M, Harrigan M (2007) Cerebrovascular dissections—a review. Part I: spontaneous dissections. Neurosurgery 68:242–257

    Article  Google Scholar 

  14. Gui L, Shi G, Li G, Fan W, Huang H, Zhou Z et al (2010) Spontaneous vertebral artery dissection: report of 16 cases. Neurol India 58:869–874

    Article  PubMed  Google Scholar 

  15. Halbach V, Higashida R, Dowd C, Fraser K, Smith T, Teitelbaum G et al (1993) Endovascular treatment of vertebral artery dissections and pseudoaneurysms. J Neurosurg 79:183–191

    Article  PubMed  CAS  Google Scholar 

  16. Hamada J, Kai Y, Morioka M, Yano S, Todaka T, Ushio Y (2003) Multimodal treatment of ruptured dissecting aneurysms of the vertebral artery during the acute stage. J Neurosurg 99:960–966

    Article  PubMed  Google Scholar 

  17. Hassan A, Zacharatos H, Souslian F, Suri M, Qureshi A (2012) Long-term clinical and angiographic outcomes in patients with cervico-cranial dissections treated with stent placement: a meta-analysis of case series. J Neurotrauma 29:1342–1353

    Article  PubMed  Google Scholar 

  18. Huang Y, Chen Y, Wang Y, Tu Y, Jeng J, Liu H (2009) Cervicocranial arterial dissection: experience of 73 patients in a single center. Surg Neurol S2:20–27

    Article  Google Scholar 

  19. Iihara K, Sakai N, Murao K, Sakai H, Higashi T, Kogure S et al (2002) Dissecting aneurysms of the vertebral artery: a management strategy. J Neurosurg 97:259–267

    Article  PubMed  Google Scholar 

  20. Jin S, Kwon D, Choi C, Ahn J, Kwun B (2009) Endovascular strategies for vertebrobasilar dissecting aneurysms. AJNR 30:1518–1524

    Article  PubMed  Google Scholar 

  21. Joo J, Ahn J, Chung Y, Han I, Chung S, Yoon P et al (2005) Treatment of intra- and extracranial arterial dissections using stents and embolization. Cardiovasc Intervent Radiol 28:595–602

    Article  PubMed  Google Scholar 

  22. Kai Y, Hamada J, Morioka M, Ohmori Y, Watanabe M, Hirano T et al (2012) Dissecting aneurysms of the vertebral artery—angiographic patterns at the dissecting site on balloon test occlusion. Neuroradiology 5:857–862

    Article  Google Scholar 

  23. Kai Y, Hamada J, Morioka M, Todaka T, Mizuno T, Ushio Y (2003) Endovascular coil trapping for ruptured vertebral artery dissecting aneurysms by using double microcatheters technique in the acute stage. Acta Neurochir 145:447–451

    PubMed  CAS  Google Scholar 

  24. Kashiwazaki D, Ushikoshi S, Asano T, Kuroda S, Houkin K (2013) Long-term clinical and radiological results of endovascular internal trapping in vertebral artery dissection. Neuroradiology 55:201–206

    Article  PubMed  Google Scholar 

  25. Kim B, Kim S, Kim D, Shin Y, Suh S, Kim D et al (2011) Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection. Neurology 76:1735–1741

    Article  PubMed  CAS  Google Scholar 

  26. Kim C, Son Y, Paek S, Han M, Kim J, Chung Y et al (2006) Clinical analysis of vertebrobasilar dissection. Acta Neurochir 148:395–404

    Article  PubMed  Google Scholar 

  27. Kocaeli H, Chaalala C, Andaluz N, Zuccarello M (2009) Spontaneous intradural vertebral artery dissection: a single-center experience and review of the literature. Skull Base 19:209–218

    Article  PubMed  PubMed Central  Google Scholar 

  28. Kudo T, Iihara K, Satow T, Murao K, Miyamoto S (2007) Incidence of ischemic complications after endovascular treatment for ruptured dissecting vertebral artery aneurysms. Interv Neuroradiol 13:157–162

    PubMed  PubMed Central  Google Scholar 

  29. Kurata A, Yamada M, Ohmomo T, Hirayama H, Suzuki S, Miyasaka Y et al (2001) The efficacy of coil embolization at the dissection site of ruptured dissecting vertebral artery aneurysms. Interv Neuroradiol 7:73–82

    PubMed  CAS  PubMed Central  Google Scholar 

  30. Lee J, Kim T, Joo S, Yoon W, Choi H (2010) Endovascular treatment of ruptured dissecting vertebral artery aneurysms—long-term follow-up results, benefits of early embolization and predictors of outcome. Acta Neurochir 152:1455–1465

    Article  PubMed  Google Scholar 

  31. Lee Y, Ahn J, Han I, Chung Y, Hong C, Joo J (2007) Therapeutic endovascular treatments for traumatic vertebral artery injuries. J Trauma 62:886–891

    Article  PubMed  Google Scholar 

  32. Luo C, Chang C, Teng M, Chang F (2005) Endovascular treatment of ruptured vertebral dissecting aneurysms with electrodetachable coils. J Chin Med Assoc 68:578–584

    Article  PubMed  Google Scholar 

  33. Lv X, Jiang C, Li Y, Wu Z (2010) Clinical outcomes of ruptured and unruptured vertebral artery-posterior inferior cerebellar artery complex dissecting aneurysms after endovascular embolization. AJNR 31:1232–1236

    Article  PubMed  CAS  Google Scholar 

  34. Lylyk P, Cohen J, Ceratto R, Ferrario A, Miranda C (2001) Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils. J Neurosurg 94:427–432

    Article  PubMed  CAS  Google Scholar 

  35. Malek A, Halbach V, Phatouros C, Meyers P, Dowd C, Higashida R (2000) Endovascular treatment of a ruptured intracranial dissecting vertebral aneurysm in a kickboxer. J Trauma Inj Infect Crit Care 48

  36. Manabe H, Hatayama T, Hasegawa S, Islam S, Suzuki S (2000) Coil embolisation for ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery. Neuroradiology 42:384–387

    Article  PubMed  CAS  Google Scholar 

  37. Mangiafico S, Padolecchia R, Cellerini M, Puglioli M, Villa G, Nistri M (2003) Rebleeding and ischemia after acute endovascular treatment of ruptured dissecting subarachnoid vertebral artery aneurysms. Interv Neuroradiol 9:205–212

    PubMed  CAS  PubMed Central  Google Scholar 

  38. Mas J, Bousser M, Hasboun D, Laplane D (1987) Extracranial vertebral artery dissections: a review of 13 cases. Stroke 18:1037–1047

    Article  PubMed  CAS  Google Scholar 

  39. Mokri B, Houser O, Sandok B, Piepgras D (1988) Spontaneous dissections of the vertebral arteries. Neurology 38:880–885

    Article  PubMed  CAS  Google Scholar 

  40. Naito I, Iwai T, Sasaki T (2002) Management of intracranial vertebral artery dissections initially presenting without subarachnoid hemorrhage. Neurosurgery 51:930–938

    PubMed  Google Scholar 

  41. Naito I, Takatama S, Shimaguchi H, Iwai T (2004) Endovascular treatment of vertebral artery dissecting aneurysms using stents. Interv Neuroradiol 10:181–186

    PubMed  PubMed Central  Google Scholar 

  42. Park K, Park J, Hwang S, Im S, Shin W, Kim B (2008) Vertebral artery dissection: natural history, clinical features and therapeutic considerations. J Korean Neurosurg Soc 44:109–115

    Article  PubMed  PubMed Central  Google Scholar 

  43. Peluso J, van Rooij W, Sluzewski M, Beute G, Majoie C (2008) Endovascular treatment of symptomatic intradural vertebral dissecting aneurysms. AJNR 29:102–107

    Article  PubMed  CAS  Google Scholar 

  44. Pham M, Rahme R, Arnaout O, Hurley M, Bernstein R, Batjer H et al (2011) Endovascular stenting of extracranial carotid and vertebral artery dissections: a systematic review of the literature. Neurosurgery 68:856–866

    PubMed  Google Scholar 

  45. Purkayastha S, Gupta K, Krishnamoorthy T, Bodhey N (2006) Endovascular treatment of ruptured posterior circulation dissecting aneurysms. J Neuroradiol 33:329–337

    Article  PubMed  CAS  Google Scholar 

  46. Rabinov J, Hellinger F, Morris P, Ogilvy C, Putman C (2003) Endovascular management of vertebrobasilar dissecting aneurysms. AJNR 24:1421–1428

    PubMed  Google Scholar 

  47. Ramgren B, Cronqvist M, Romner B, Brandr L, Holtas S, Larsson E (2005) Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients. Neuroradiology 47:97–104

    Article  PubMed  CAS  Google Scholar 

  48. Rubinstein S, Peerdeman S, van Tulder M, Riphagen I, Haldeman S (2005) A systematic review of the risk factors for cervical artery dissection. Stroke 36:1575–1580

    Article  PubMed  Google Scholar 

  49. Santos-Franco J, Zenteno M, Lee A (2008) Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options. Neurosurg Rev 31:131–140

    Article  PubMed  Google Scholar 

  50. Sasaki O, Ogawa H, Koike T, Koizumi T, Tanaka R (1991) A clinicopathological study of dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 75:874–882

    Article  PubMed  CAS  Google Scholar 

  51. Schievink W, Wijdicks E, Michels V (1998) Heritable connective tissue disorders in cervical artery dissections: a prospective study. Neurology 50:1166

    Article  PubMed  CAS  Google Scholar 

  52. Shah Q, Messé S (2007) Cervicocranial arterial dissection. Curr Treat Options Neurol 9:55–62

    Article  PubMed  Google Scholar 

  53. Shin Y, Kim B, Kim S, Suh S, Ryu C, Koh J et al (2012) Endovascular treatment of bilateral intracranial vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage. Neurosurgery 70:ons75–ons81

    Google Scholar 

  54. Su W, Gou S, Ni S, Li G, Liu Y, Zhu S et al (2011) Management of ruptured and unruptured intracranial vertebral artery dissecting aneurysms. J Clin Neurosci 18:1639–1644

    Article  PubMed  Google Scholar 

  55. Sugiu K, Tokunaga K, Watanabe K, Sasahara W, Ono S, Tamiya T et al (2005) Emergent endovascular treatment of ruptured vertebral artery dissecting aneurysms. Neuroradiology 47:158–164

    Article  PubMed  CAS  Google Scholar 

  56. Taha M, Sakaida H, Asakura F, Maeda M, Toma N, Yamamoto A et al (2010) Endovascular management of vertebral artery dissecting aneurysms: review of 25 patients. Turk Neurosurg 20:126–135

    PubMed  Google Scholar 

  57. Thanvi B, Munshi S, Dawson S, Robinson T (2005) Carotid and vertebral artery dissection syndromes. Postgrad Med J 81:383–388

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  58. Touzé E, Randoux B, Méary E, Arquizan C, Meder J, Mas J (2001) Aneurysmal forms of cervical artery dissection. Stroke 32:418–423

    Article  PubMed  Google Scholar 

  59. Tsukahara T, Wada H, Satake K, Yaoita H, Takahashi A (1995) Proximal balloon occlusion for dissecting vertebral aneurysms accompanied by subarachnoid hemorrhage. Neurosurgery 36:914–920

    Article  PubMed  CAS  Google Scholar 

  60. Xu R, Liu W, Li J, Liu X, Hao D, Zhang T (2013) Endovascular intervention of intradural hemorrhage from ruptured spontaneous vertebral artery dissection. Neurosciences 18:46–51

    PubMed  Google Scholar 

  61. Yamaura I, Tani E, Yokota M, Nakano A, Fukami M, Kaba K et al (1999) Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Gugliemi detachable coils. J Neurosurg 90:853–856

    Article  PubMed  CAS  Google Scholar 

  62. Yasui T, Komiyama M, Nishikawa M, Nakajima H (2000) Subarachnoid hemorrhage from vertebral artery dissecting aneurysms involving the origin of the posteroinferior cerebellar artery: report of two cases and review of the literature. Neurosurgery 46:196

    Article  PubMed  CAS  Google Scholar 

  63. Yoon W, Seo J, Kim T, Do H, Jayaraman M, Marks M (2007) Dissection of the V4 segment of the vertebral artery: clinicoradiologic manifestations and endovascular treatment. Eur Radiol 17:983–993

    Article  PubMed  Google Scholar 

  64. Yoshimoto Y, Wakai S (1997) Unruptured intracranial vertebral artery dissection. Stroke 28:370–374

    Article  PubMed  CAS  Google Scholar 

  65. Youl B, Coutellier A, Dubois B, Leger J, Bousser M (1990) Three cases of spontaneous extracranial vertebral artery dissection. Stroke 21:618–625

    Article  PubMed  CAS  Google Scholar 

  66. Zhao W, Krings T, Alvarez H, Ozanne A, Holmin S, Lasjaunias P (2007) Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: review of 21 consecutive cases. Acta Neurochir 149:585–596

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Neurosurgical Service, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Wang 745, Boston, MA, USA

    Silvia Hernández-Durán & Christopher S. Ogilvy

  2. University of Costa Rica School of Medicine, Ciudad Universitaria Rodrigo Facio, San Pedro de Montes de Oca, San José, Costa Rica

    Silvia Hernández-Durán

  3. Apdo. 1232-1007, San José, Costa Rica

    Silvia Hernández-Durán

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  1. Silvia Hernández-Durán
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Correspondence to Silvia Hernández-Durán.

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Takuma Wakai and Hiroyuki Kinouchi, Yamanashi, Japan

The authors described the results of a meta-analysis on 39 studies regarding endovascular treatments for 637 patients with vertebral artery (VA) dissection and showed the efficacy and safety of these modalities. This paper is suggestive and has clinical relevance since the number of cases has been increased by the introduction of magnetic resonance imaging into a diagnostic tool in acute stroke and also endovascular treatment has been considered as an alternative therapy to open surgery in VA dissection especially in cases with subarachnoid hemorrhage (SAH).

This study provided detailed clinical outcomes and angiographic results in VA dissections treated by different endovascular techniques, including stenting, stent-assisted coiling, parent vessel occlusion by means of coiling or balloons, balloon-assisted coiling, and proximal occlusion. The majority of the lesions had an intracranial location, and the most common clinical presentation was SAH followed by ischemia and other symptoms. Posterior inferior cerebellar artery involvement was seen in about 15 %. This paper showed the superiority of endovascular treatments in VA dissections; however, only proximal occlusion could not achieve good clinical outcome and angiographic improvement compared to other treatments. Proximal occlusion was more likely to be applied to SAH patients, and as pointed out, this has been performed in technically complex lesions such as those involving branches or difficult to treat with coils or balloons. It has been known that the cure of VA dissention would be to eradicate the lesion from the arterial bloodstream by trapping with or without bypass. Therefore, proximal occlusion cannot preclude the dissection from being reruptured or regrown [1]. Recently, the pipeline embolization device was introduced as the flow-diverting device intended to exclude the aneurysm hemodynamically from the parent artery preserving blood flow through covered arterial branches [2–3]. This new device might achieve higher curability with less ischemic complications for the lesion involving branches. The reduced operative time, minimal invasiveness, and overall safety render endovascular treatment a suitable option for intervention-amenable dissections.

Meanwhile, unruptured VA dissections usually have a benign nature [4] and have a tendency to be treated with conservative therapy. This paper did not show any evidence revealing endovascular treatment is superior to conservative treatment. Further study is necessary to determine the suitable management for unruptured VA dissection.

References

1. Rabinov JD, Hellinger FR, Morris PP, Ogilvy CS, Putman CM (2003) Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol. 24:1421–1428

2. Yeung TW, Lai V, Lau HY, Poon WL, Tan CB, Wong YC (2012) Long-term outcome of endovascular reconstruction with the pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery. J Neurosurg. 116:882–887

3. Cruz JP, O’Kelly C, Kelly M, Wong JH, Alshaya W, Martin A, et al (2013) Pipeline embolization device in aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol. 34:271–276

4. Yoshimoto Y, Wakai S. (1997) Unruptured intracranial vertebral artery dissection. Clinical course and serial radiographic imagings. Stroke 28:370–374

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Hernández-Durán, S., Ogilvy, C.S. Clinical outcomes of patients with vertebral artery dissection treated endovascularly: a meta-analysis. Neurosurg Rev 37, 569–577 (2014). https://doi.org/10.1007/s10143-014-0541-y

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