Rerupture mechanism of ruptured intracranial dissecting aneurysm in the vertebral artery following proximal occlusion

Proximal occlusion is commonly employed to prevent rebleeding of intracranial dissecting aneurysms of the vertebral artery (VA), but rebleeding sometimes occurs. To determine the cause of such rebleeding we reviewed nine cases, including eight reported in the literature and one created at our hospital. We classified the techniques used to proximally occlude the VA into two types. In Type I, occlusion is performed im mediately proximal to the aneurysm so that there are no perforating arteries or the posterior inferior cerebellar artery (PICA) between the clip and the aneurysm. In Type II, occlusion is performed proximal to the PICA so postoperative retrograde flow persists from the contralateral VA through the aneurysm into the ipsilateral PICA. Among the four Type I cases reviewed, it was found that the interval between occlusion and rebleeding was very short: three developed rebleeding within four hours of occlusion, and the fourth showed rebleeding on the fourth day. In the five Type II patients, rebleeding occurred more than four days (mean 15.2 days) after occlusion. It is thought that in Type I occlusion, retrograde flow into the aneurysm immediately after occlusion may raise the intraaneurysmal pressure enough to cause rerupture within just a few hours of occlusion. In Type II occlusion, postoperarive retrograde flow through the aneurysm into the ipsilateral PICA exists, so the intraaneurrysmal pressure is not likely to rise as rapidly, with the result that rebleeding occurred after more than four days probably due to recurrence of dissection. The short interval between proximal occlusion and rebleeding, especially in Type I cases, suggests that postoperative angiography is only of limited usefulness in evaluating the possibility of rebleeding. The mortality rate reported for cases with reruptured vertebral dissecting aneurysms after proximal occlusion is very high (55.6%). These data indicate that surgical trapping or endovascular intraluminal occlusion, which is difficult to perform in some patients, should be considered the most suitable procedure from the view point of preventing postoperative rebleeding.