Treatment of Dissecting Vertebral Pseudoaneurysms: A Single-Center Experience

BACKGROUND: Dissecting vertebral artery pseudoaneurysms represent a unique clinical challenge with careful appreciation for location of the posterior inferior cerebellar artery. Limited data is available in terms of outcomes regarding the various treatment modalities. METHODS: 11 patients with dissecting pseudoaneurysms were identified from 2013–2021. Pseudoaneurysm size and morphology, clinical presentation, and treatment approach was collected. Success of treatment was recorded based on post-operative imaging as well as documented overall patient outcomes. Three primary treatment modalities emerged: coil embolization, stent assisted coiling, and flow diversion. RESULTS: Of the 11 patients, 5 were female and 6 were male with an age from 36 to 69.7. 7 had ruptured pseudoaneurysms at time of treatment. Size of pseudoaneurysm ranged from 3 to 6 mm. 8 were on the right and 3 were on the left vertebral artery. 8 were proximal to PICA and 3 were distal. Co-dominance of vertebral filling was seen in 5 patients, 5 with dominance through right vertebral artery, and 1 with dominance through left vertebral artery. Variability existed in treatment approaches with 4 patients undergoing coil occlusion, 5 patients undergoing flow diversion stenting, and 2 patients undergoing flow diversion stenting with jailed coiling. 1 patient had enlargement of pseudoaneurysm while inpatient and required a second flow diversion device. 1 patient had two flow diversion devices placed initially at time of treatment due to morphology of PA. 6 patients had repeat angiograms between 6 to 9 months with complete occlusion. 3 had CTA or MRA with complete occlusion for those that had flow diversion, they were transitioned from aspirin and clopidogrel to aspirin monotherapy after first repeat angiogram. 6 patients required shunt placement for hydrocephalus. 1 patient died prior to discharge due to sepsis. 2 patients died post discharge: 1 with myocardial infarction and the 2nd due to urosepsis. Dissecting vertebral pseudoaneurysm has high morbidity and mortality if rupture occurs. Location of PICA origin influences treatment approach. Patients with poor Hunt/Hess scores upon arrival had increased risk for systemic infection and mortality.