Optimizing surgical strategies for ruptured vertebral artery dissecting aneurysms: experience with perforator bypass...

Ruptured vertebral artery dissecting aneurysms (rVADAs) are life-threatening lesions with a high risk of rebleeding and brainstem infarction. This study describes our institutional experience with open surgical management of rVADAs, with a focus on perforator bypass strategies. We retrospectively analyzed 17 patients with rVADAs treated surgically between 2012 and 2025. Clinical data, imaging characteristics, surgical details, and outcomes were reviewed. Special attention was given to cases with perforator involvement and the use of bypass reconstruction. Clinical outcomes were assessed using the modified Rankin Scale (mRS) at discharge and follow-up. Perforator involvement was identified in 9 cases (52.9%). Perforator bypass was performed in 6 cases, with no postoperative medullary infarction. In contrast, among 3 cases without bypass, 2 (66.7%) developed medullary infarction, both with poor neurological outcomes. One case of rebleeding occurred where the dissection was intentionally left to preserve the posterior inferior cerebellar artery, underscoring the importance of complete trapping of all dissected segments. Among 8 patients with WFNS Grade V, 5 (62.5%) achieved favorable outcomes, which may be associated with hyperacute surgical clot removal and brainstem decompression. There was no perioperative mortality, and bypass patency was confirmed intraoperatively in all cases. Open surgical management offers key advantages in rVADA treatment, including precise identification of dissection extent, complete aneurysm exclusion, and perforator reconstruction when critical branches are involved. Perforator bypass has the potential to reduce the risk of brainstem infarction and improve outcomes without compromising aneurysm treatment. Moreover, hyperacute surgical intervention may contribute to favorable outcomes even in poor-grade subarachnoid hemorrhage. With appropriate microsurgical training, these techniques may be applicable in specialized centers, although further multicenter studies are needed to validate these findings.