In 6 patients the vertebral artery (VA) was affected, in 2 patients the basilar artery (BA), in 3 the internal carotid (ICA), in 1 the middle cerebral (MCA) and in 1 the postcommunicating (A2) segment of the anterior cerebral artery (ACA). Maintaining arterial patency was aimed at in all patients. Tangential clipping or circumferential wrapping were used as surgical methods. Endovascular stenting and/or coiling was applied in 2 instances. Four of the 6 VA
dissecting aneurysms underwent surgical exploration between 1 and 22 days after haemorrhage. Two patients were in WFNS grade V and died subsequently with the
aneurysms untreated, one after rehaemorrhage. In the patients with secured VA
aneurysms the postoperative course was uncomplicated with the exception of additional caudal
cranial nerve injury in 1 instance. Both BA
aneurysms were initially treated by endovascular methods. In the first patient incomplete packing with Gugliemi detachable (GDC) coils was achieved. Follow-up angiography 6 months later showed growth and coil compaction and subsequent wrapping with
Teflon fibres resulting in angiographic stabilization. The other BA
aneurysm was treated by a combination of a coronary
stent and GDC coils. The 3 dissecting ICA
aneurysms were all explored surgically. In only 1 instance ICA continuity could be preserved by wrapping, in the other 2 cases a major portion of the vessel wall disintegrated upon removal of the surrounding clot. The only ACA
dissecting aneurysm, on A2, was successfully treated with a
Dacron cuff. In the single patient with a MCA
aneurysm, a decision for
conservative management was taken, because neither a surgical nor an endovascular
solution was seen as a possibility that did not risk occlusion of lenticulostriate branches. The patient suffered a fatal rehaemorrhage 4 weeks later at her home.
CONCLUSIONS: The reported experience suggests that in Western countries also
dissecting aneurysms are an occasional source of SAH. The outcome in our conservatively managed patients confirms the poor prognosis of
conservative management. Wrapping and endovascular
stent based methods can achieve stabilization of the dissected artery without sacrificing the artery. Results of treatment appear to depend largely on the location of the
dissecting aneurysm.