Korean Journal of Cerebrovascular Surgery 2011;13(1):19-23.
Published online March 1, 2011.
Internal Trapping Using Detachable Coils for Ruptured Vertebral Artery-dissecting Aneurysms: Case Report.
Lee, Seung Hwan , Lim, Dong Jun , Ha, Sung Kon , Kim, Sang Dae , Kim, Se Hoon , Park, Jung Yul
1Department of Neurosurgery, Ansan Hospital, Korea University Medical Center, Korea. djlim@korea.ac.kr
2Department of Neurosurgery, Guro Hospital, Korea University Medical Center, Korea.
Ruptured vertebral artery- dissecting aneurysms (VADAs) must be treated as early as possible due to frequent rebleeding in the early stage. We have reported herein two patients with VADAs who were treated using internal trapping using detachable coils. Both patients were young females in their 40's. They had been admitted to the emergency clinic due to severe headaches and mental deterioration. Brain computed tomography (CT) scans revealed a subarachnoid hemorrhages in the posterior fossa, and transfemoral catheter cerebral angiography revealed dissecting aneurysms at the dominant vertebral arteries. Under general anesthesia, embolization of the parent artery, including the aneurysmal portion, using Guglielmi detachable coils was performed without any procedural complications. Before the induction of general anesthesia, a balloon test occlusion was done on both patients. Both patients improved well after surgery. One patient underwent cerebral angiography at six months after surgery and showed no recurrence of the aneurysm or recanalization of the parent artery. Both patients were free of neurologic findings on follow-up at the 6- and 12- month. Based on these results, patients with ruptured VADAs, located in the dominant vertebral arteries, may be successfully treated with urgent internal trapping using an endovascular technique in selected cases.
Key Words: Subarachnoid hemorrhage, Dissecting aneurysm, Vertebral artery, Balloon occlusion, Therapeutic embolization


An increasing number of patients with subarachnoid hemorrhage (SAH) caused by vertebral artery dissecting aneurysms (VADAs) are being reported.1-7) Recent reports have suggested that recurrent bleeding from an unsecured VADA is extremely high (50%~70%) and usually occurs within 24 hours of the initial rupture.1)5)8) These reports had indicated that very early treatment of the ruptured VADA is required to prevent fatal rebleeding.1)3)5) Although many surgical and endovascular treatments for ruptured VADAs have been reported, the question of optimum treatment remains controversial. We have reported our experience with endovascular treatment in two patients with ruptured VADAs. We have reviewed these cases and have discussed the treatment and outcome of dissecting vertebral aneurysms.


Case Descriptrion

Case 1

A 36-year-old woman presented with the sudden onset of headache, vomiting, and disturbance of consciousness. A computed tomography (CT) scan showed a suba- rachnoid hemorrhage (SAH; Fig. 1 A). Subsequent cerebral angiography delineated a dissecting aneurysm of the left vertebral artery (VA), with a typical pearl-and-string sign (Fig. 1 B). The posterior inferior cerebellar artery (PICA) was not visualized, which was consistent with a type IV (non-PICA) VADA according to the Mizutani classification.5) Because the blood supply through the right VA had been sufficient and PICA had not been definite, we believed that the left VA could be sacrificed without any neurologic consequences.

Prior to occlusion of the left VA, a preliminary test occlusion of the left VA was performed using a 4 x 20 mm Savvy balloon (Cordis Corporation, Miami Lakes, FL, USA). The test balloon was positioned at the extracranial portion of the VA and inflated for 40 minutes. For the first 20 minutes, the patient had neurologic monitoring. Then, hypotension was provoked using a calcium channel blocker for another 20 minutes. The patient tolerated balloon test occlusion, and did not present with any neurologic symptoms. Following a successful test occlusion, the parent vessel, including the dissecting aneurysm, was completely occluded with 13 Guglielmi detachable coils (GDCs; two 5 mm x 15 cm, two 5 mm x 9 cm, two 4 mm x 8 cm, two 3 mm x 8 cm, three 3 mm x 6 cm, 2 mm x 6 cm, and 2 mm x 4 cm coils) introduced through an Excelsior SL-10 microcatheter (Boston Scientific, USA) (Fig. 1 C and D). The procedure was successful and free from complications. A post-operative right vertebral angiogram revealed good flow to the basilar artery (E).

Six months after the embolization, follow-up angiography was performed, which revealed preservation of the total occlusion state in the left VA (Fig. 1 D). It was determined that no further intervention was needed. At the last clinical follow-up, 12 months after the emboli- zation, the patient had recovered fully.

Case 2

A 39-year-old woman was transferred to our hospital after having a sudden, severe headache and loss of consciousness. At the time of admission, the neurologic status was classified as grade 2 according to the Hunt-Hess grading system. A CT scan revealed SAH, and cerebral angiography demonstrated a dissecting aneurysm of the dominant, right VA (Fig. 2 A). The dissection was located at the intradural segment of the right VA distal to the PICA, which was consistent with a type I (post-PICA) VADA according to the Mizutani classification.5) The left vertebral angiogram revealed that the left VA ended in the PICA (Fig. 2 B).

The patient tolerated a balloon test occlusion using a Hyper Form balloon (Microtherapeutics, USA; Fig. 2 C). The aneurysmal sac and the right VA were completely occluded with 6 GDCs (one 4 mm x 8 cm, two 2 mm x 6 cm, one 2 mm x 4 cm, and one 2 mm x 2 cm coils) under general anesthesia (Figs. 2 D and E). The right PICA was preserved and the flow to the vertebrobasilar system was preserved through the right internal carotid artery via the posterior communicating artery (Fig. 2 F). The patient had a full neurologic recovery the next day and an uneventful post-operative course. The patient was discharged and has remained well for the last 6 months.


Recently, VADAs have been recognized with increasing frequency as a cause of stroke, which often leads to SAH. Further, VADAs have been demonstrated to have a high rate of rebleeding associated with a grim prognosis.1-3)7) Recurrent hemorrhage has generally occurred during the acute stage, usually within several hours after the initial SAH5)8). Therefore, urgent treatment for preventing fatal recurrent hemorrhage is needed.9)

The mechanism of arterial dissection has been thought to be a sudden disruption of the internal elastic lamina and subsequent penetration of circulating blood into the media. Depending on the depth of the vessel wall dissection, clinical presentation can be defined. If the internal elastic lamina has been disrupted by the dissection, SAH has been shown to occur.10)

Common methods of surgical management have included proximal occlusion of the VA, trapping, direct clipping, and vertebral arterial reconstruction. However, several authors have reported that some surgical strategies for ruptured VADAs are unsuitable in the acute stage because of a high incidence of complications.5)11) For example, Kitanaka, et al.12) reported that 29% of patients treated surgically for ruptured VADAs exhibited new post-operative deficits.12) Further, Mizutani, et al.5) reported a complication rate of 31.3% for the early surgical treatment of ruptured VADAs.5)

With the development of endovascular treatment, especially with the introduction of the GDC, end- ovascular treatment has become safer and more effective because most coils are soft and easily controlled1)4)6-7) Thus, endovascular treatment has shifted from proximal occlusion to internal trapping, in which the dissected site is completely occluded with detachable coils.7) Recently, a number of reports have demonstrated the efficacy of endovascular coil embolization for ruptured VADAs. On the basis of data culled from the literature, the endovascular approach is the best for treating ruptured VADAs in the acute stage.1)4)6-7) However, many neurosurgeons continue to render surgical treatment, thus the need for early treatment of ruptured VADAs is recognized; however, the optimal treatment has not been determined.

Because the endovascular approach using detachable coils has included the sacrifice of the affected VA, there are several limitations to this treatment, as follows: (1) bilateral lesions; (2) a hypoplastic contralateral VA; (3) PICA involved type (type II); and (4) a dissecting aneurysm that includes the basilar artery. In patients with VADAs, the best treatment may be surgical or endovascular trapping of the lesion, combined with bypass surgery, such as an occipital artery–PICA anastomosis, or using new endovascular techniques, including stent technology.2-3)13-15)

In our cases, the dissecting aneurysms were located at the dominant VAs. However, the contralateral VAs were not hypoplastic and collateral flow to the vertebrobasilar circulation was sufficient, as confirmed by the balloon test occlusion. Therefore, both cases were treated uneventfully with standard endovascular occlusion sacrificing the parent arteries. Thus, as in our cases, when dissections involve the dominant VA, a balloon test occlusion may be useful in evaluating the collateral circulation via the contralateral VA or posterior communicating arteries to the vertebrobasilar circulation.16)


Based on our results, and the results of previous studies, we suggest that immediate internal coil trapping is the preferred therapy in the acute phase of SAH after vertebral dissection. Even in cases of ruptured VADAs on dominant VAs, if a balloon test occlusion is tolerable, internal trapping using detachable coils may be a desirable treatment in select cases.


1) Aoki N, Sakai T. Rebleeding from intracranial dissecting aneurysm in the vertebral artery. Stroke 21:1628-31, 1990

2) Benndorf G, Herbon U, Sollmann WP, Campi A. Treatment of a ruptured dissecting vertebral artery aneurysm with double stent placement: case report. AJNR Am J Neuroradiol 22:1844-48, 2001

3) Horowitz MB, Purdy PD. The use of stents in the management of neurovascular disease: a review of historical and present status. Neurosurgery 46:1335-1342; discussion 1342-33, 2000

4) Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14-20, 1968

5) Iihara K, Sakai N, Murao K, Sakai H, Higashi T, Kogure S, et al. Dissecting aneurysms of the vertebral artery: a management strategy. J Neurosurg 97:259-67, 2002

6) Inoue A, Kohno K, Takechi A, Matsushige T, Takeda T. Bilateral vertebral artery dissecting aneurysm with subarachnoid hemorrhage treated with staged bilateral vertebral artery coil occlusion: a case report. Surg Neurol 70:319-22; discussion 322, 2008

7) Kitanaka C, Sasaki T, Eguchi T, Teraoka A, Nakane M, Hoya K. Intracranial vertebral artery dissections: clinical, radiological features, and surgical considerations. Neurosurgery 34:620-6; discussion 626-7, 1994

8) Koh JS, Ryu CW, Lee SH, Bang JS, Kim GK. Bilateral vertebral-artery-dissecting aneurysm causing subarachnoid hemorrhage cured by staged endovascular reconstruction after occlusion. Cerebrovasc Dis 27:202-4, 2009

9) Kurata A, Ohmomo T, Miyasaka Y, Fujii K, Kan S, Kitahara T. Coil embolization for the treatment of ruptured dissecting vertebral aneurysms. AJNR Am J Neuroradiol 22:11-8, 2001

10) Lylyk P, Ceratto R, Hurvitz D, Basso A. Treatment of a vertebral dissecting aneurysm with stents and coils: technical case report. Neurosurgery 43:385-8, 1998

11) Lylyk P, Cohen JE, Ceratto R, Ferrario A, Miranda C. Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils. J Neurosurg 94:427-32, 2001

12) Manabe H, Hatayama T, Hasegawa S, Islam SM, Suzuki S. Coil embolisation for ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery. Neuroradiology 42:384-7, 2000

13) Mizutani T, Aruga T, Kirino T, Miki Y, Saito I, Tsuchida T. Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 36:905-911; discussion 912-3, 1995

14) Mizutani T, Kojima H, Asamoto S. Healing process for cerebral dissecting aneurysms presenting with subarachnoid hemorrhage. Neurosurgery 54:342-7; discussion 347-8, 2004

15) Park SI, Kim BM, Kim DI, Shin YS, Suh SH, Chung EC, et al. Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 30:1351-6, 2009

16) Peluso JP, van Rooij WJ, Sluzewski M, Beute GN, Majoie CB. Endovascular treatment of symptomatic intradural vertebral dissecting aneurysms. AJNR Am J Neuroradiol 29:102-106, 2008

17) Ramgren B, Cronqvist M, Romner B, Brandt L, Holtas S, Larsson EM. Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients. Neuroradiology 47:97-104, 2005

18) Sugiu K, Takahashi K, Muneta K, Ohmoto T. Rebleeding of a vertebral artery dissecting aneurysm during stent-assisted coil embolization: a pitfall of the "stent and coil" technique. Surg Neurol 61:365-70; discussion 370, 2004

19) Sugiu K, Tokunaga K, Watanabe K, Sasahara W, Ono S, Tamiya T, et al. Emergent endovascular treatment of ruptured vertebral artery dissecting aneurysms. Neuroradiology 47:158-64, 2005

20) Suh SH, Kim BM, Park SI, Kim DI, Shin YS, Kim EJ, et al. Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery. Clinical article. J Neurosurg 111:48-52, 2009

21) Suzuki S, Kurata A, Iwamoto K, Sato K, Niki J, Miyazaki T, et al. Endovascular surgery using stents for vertebral artery dissecting aneurysms and a review of the literature. Minim Invasive Neurosurg 51:193-8, 2008

22) Tsukahara T, Wada H, Satake K, Yaoita H, Takahashi A. Proximal balloon occlusion for dissecting vertebral aneurysms accompanied by subarachnoid hemorrhage. Neurosurgery 36:914-9; discussion 919-20, 1995

23) Yamaura I, Tani E, Yokota M, Nakano A, Fukami M, Kaba K, et al. Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Guglielmi detachable coils. J Neurosurg 90:853-6, 1999

Editorial Office
The Journal of Cerebrovascular and Endovascular Neurosurgery (JCEN), Department of Neurosurgery, Wonkwang University
School of Medicine and Hospital, 895, Muwang-ro, Iksan-si, Jeollabuk-do 54538, Korea
Tel: +82-2-2279-9560    Fax: +82-2-2279-9561    E-mail: editor.jcen@the-jcen.org                

Copyright © 2023 by Korean Society of Cerebrovascular Surgeons and Korean NeuroEndovascular Society.

Developed in M2PI

Close layer
prev next