Stroke Center, Department of Neurosurgery, Teishinkai Hospital, Sapporo, Japan.
J Neurosurg. 2016 Oct;125(4):953-963. doi: 10.3171/2015.8.JNS15362. Epub 2016 Feb 5.
OBJECTIVE Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery. METHODS Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms. RESULTS The post-coil embolization patients underwent V-posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V-V or V-V bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable. CONCLUSIONS Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.
双侧椎动脉夹层动脉瘤（VADA）预后较差，因为动脉瘤的进行性增大压迫脑干或导致蛛网膜下腔出血。1 条椎动脉（VA）的闭塞会增加对侧 VA 的血流动力学压力，可能导致其增大和破裂。因此，治疗策略存在争议。本研究描述了一种使用旁路手术治疗双侧 VADA 的激进治疗方法。
纳入 7 例双侧 VADA 患者。3 例患者在另一家医院通过线圈或夹闭闭塞 1 条 VA 进行治疗；1 例患者此前治疗过的 VA 和 2 例患者未治疗过的对侧 VA 随后增大。另外 4 例患者无既往干预，动脉瘤逐渐增大。
血管内线圈栓塞后的患者接受 V-大脑后动脉（PCA）旁路和闭塞。另外 4 例患者通过 V-V 或 V-V 旁路进行 VA 重建，其中 3 例在另一天对侧进行闭塞，1 例进行观察。围手术期并发症包括 1 例因乙状窦血栓形成导致的脑脊液漏需再次手术，1 例吞咽困难和面瘫，1 例吞咽困难。这些患者的长期预后良好。
双侧 VADA 患者需要双侧治疗。如果首先进行 VA 闭塞，另一侧的治疗选择仅限于 V-PCA 旁路和闭塞。该手术有效，但也具有侵袭性和技术难度。对于可以重建 1 侧的双侧 VADA 病例，最好的方法是首先重建技术上最简单的 VA，然后再闭塞对侧 VADA。这种策略可以留出足够的时间缝合血管，因为可以维持对侧反向血流。
