Reconsideration of microsurgery for endovascularly high-risk ruptured vertebral artery dissection

Endovascular therapy is commonly used for ruptured vertebral artery dissecting aneurysm (VADA); however, complications such as medullary infarction and posterior inferior cerebellar artery (PICA)-related ischemia remain concerns, especially in long lesions distal to the PICA. Direct surgery offers advantages, including minimal trapping length, perforator preservation, and bypass availability. This study aimed to evaluate clinical outcomes of direct surgery for ruptured VADA and reassess its strategy.

We retrospectively reviewed patients with ruptured VADA who underwent direct surgery over a 12-year period. Data included demographics, neurological status, surgical procedure, lesion characteristics, aneurysm obliteration, complications, and outcomes assessed using the modified Rankin Scale (mRS) at the final follow-up.

Nineteen patients were analyzed: proximal-to-PICA (n = 4), PICA-involved (n = 7), and distal-to-PICA (n = 8). Procedures included trapping (n = 12) and proximal artery clipping (PAC; n = 7). Occipital artery-PICA bypass was performed in three PICA-involved cases. One patient died before the final follow-up. Complete obliteration was achieved in 17 patients (94.4%), and favorable outcomes (mRS 0-2) were observed in 14 (73.7%). Medullary infarction occurred in two patients (11.1%). No significant associations were found between lesion location, length, procedure type, and outcomes.

Direct surgery yielded favorable outcomes in ruptured VADA. When PICA preservation is uncertain, bypass options may reduce ischemic complications. Lesion location and length did not significantly affect prognosis. For long or distal-to-PICA lesions, direct surgery may be a preferred strategy.