Endovascular treatments of intracranial vertebral and internal carotid arteries dissections: An interactive systematic review and meta-analysis

Abstract

Introduction

Management of intracranial artery dissection (IAD) remains elusive in medical practice. Intracranially, vertebral artery dissection (VAD) is more commonly encountered than internal carotid artery dissection (ICAD). Deconstructive (EVT-d) and reconstructive (EVT-r) endovascular techniques have been utilized to treat VAD and ICAD. This meta-analysis investigates the safety and efficacy of EVT-r and EVT-d in the management of VAD and ICAD.

Methods

The literature was searched for all studies with consecutive patient series evaluating EVT-d or EVT-r for VAD or ICAD management. Baseline characteristics and outcomes were compared between EVT-r and EVT-d groups using the random-effect model and meta-regression approaches.

Results

Overall, 1095 cases pooled from 56 studies were included. There was no statistically significant difference in baseline characteristics between VAD and ICAD. EVT-r was applied in 647 cases (59.1%) and EVT-d in the rest There was no statistical difference in the rate of procedural complications between EVT-r and EVT-d. Although EVT-d was significantly associated with higher rates of complete aneurysm occlusion (86.4%), lower rates of good clinical outcomes (72.1%) and higher mortality (15.1%) were achieved compared to EVT-r (70.2%, 83.3%, and 9.5%; respectively). The mortality rate was higher, and good clinical outcomes were less common in ruptured aneurysms. Ischemic presentation was statistically associated with poor outcomes (mRS 3-5) but low mortality. ICAD often tended to grow following treatment and resulted in poor neurological outcomes.

Conclusions

IAD has favorable outcomes when treated appropriately. Novel reconstructive endovascular techniques are promising and should be integrated well in endovascular practice. Further studies are warranted.

Keywords

Vertebral artery internal carotid artery dissection endovascular reconstructive deconstructive parent artery occlusion

Introduction

Intracranial artery dissection (IAD), especially symptomatic ones leading to subarachnoid hemorrhage (SAH), acute ischemic stroke, or compression, are associated with high morbidity and mortality rates when left untreated.^1–3 IAD more commonly affects the posterior circulation and the vertebral arteries, much less frequently, the internal carotid artery and anterior circulation.⁴ Endovascular treatments (EVT) have emerged as a successful option to manage symptomatic IAD. Various deconstructive endovascular (EVT-d) approaches, such as trapping or sacrifice of the parent vessel harboring ruptured dissecting aneurysms, have been heavily used to treat IAD in the past In the last twenty years, an accelerating evolution in selective endovascular techniques led to a replacement of most of the deconstructive techniques with reconstructive approaches like stenting, stent-assisted coiling, and flow diverters to preserve the parent artery, thus avoiding the harmful sequences of deconstructive techniques.

Many retrospective cohort studies evaluated the newly introduced techniques for IAD management.^5–8 Nevertheless, most case series have a relatively small sample size, and adequately powered randomized double-blinded clinical trials are lacking. A large meta-analysis comparing the reconstructive endovascular technique (EVT-r) and EVT-d for management of 478 patients with vertebrobasilar artery dissection was published in 2015.⁹ Considerable number of studies about EVT-r was published recently, which calls for an updated meta-analysis. Furthermore, investigation of the safety and efficacy of these techniques in both anterior and posterior circulation is beneficial. In this study, we investigate the safety and efficacy of EVT-r and EVT-d techniques in the management of intracranial vertebral (VAD) and internal carotid artery (ICAD) dissections.

Methods

Search strategy

The literature was searched on Pubmed, PMC, and Embase via API through the Nested Knowledge AutoLit software (AutoLit, Nested Knowledge, St Paul, MN) in December 2021 for reconstructive and deconstructive endovascular treatments of intracranial vertebral and internal carotid artery dissections. The search was performed in accordance with PRISMA guidelines. Search strategies were created using a combination of keywords, and standardized index terms included “Intracranial dissections,” “Occlusion,” “Stent,” “Parent artery sacrifice,” “Stroke,” “Subarachnoid hemorrhage” Rupture” (Appendix). Results were limited to the English language from inception until now.

Eligibility criteria

Inclusion criteria included: 1) Studies reporting a consecutive series of patients with anterior circulation (ICA) or posterior circulation (VA) dissections managed with either reconstructive (EVT-r; flow diverters, stenting, stent-assisted coiling, etc.) or deconstructive (EVT-d; parent artery sacrifice) endovascular techniques with clear reporting of the primary outcomes, 2) Series of at least five patients reporting the angiographic and clinical outcomes besides procedural complications. Exclusion criteria included: 1) Editorial or opinion article, 2) Review articles, 3) Case report or <5 patients, 4) in vitro or animal study, and 5) Secondary study of previously reported data.

Study selection process

One author screened the titles and abstracts for inclusion using Nested Knowledge's screening software. The same author retrieved full-text articles of the included abstracts and screened them, and the senior author approved all inclusion decisions.

Data extraction and outcome measures

Baseline characteristics of each study population were collected, including age, gender, lesion location, and clinical presentation (ischemic, hemorrhagic).

The included studies were subdivided into two groups. The first group comprised patients managed with EVT-r, and the second group included those who received EVT-d. To evaluate the efficacy and safety of both techniques, the clinical and angiographic outcomes and procedural complications of the treatment population for both techniques at the last follow-up were analyzed. The angiographic outcomes were represented by the intervention success rate, the complete occlusion, recurrence, and growth rates (for initially incompletely occluded or stented lesions) of treated dissecting aneurysms, and the patency rates of parent artery at last follow-up. Clinical outcomes were analyzed under three groups; good (mRS 0–2) and poor clinical outcomes (mRS 3–5) and mortality rates (mRS 6). Procedural complications were assessed as hemorrhagic and ischemic complications with attention to recurrent/de novo hemorrhage/ischemia.

Statistical analysis

The cumulative incidence (event rate per patient at the end of the study) for each study was estimated and 95% CI. We used a random-effects model to pool incidence rates across studies because of the marked heterogeneity expected in the populations and interventions across various studies. The I² statistic was used to express the proportion of inconsistency not attributable to chance. Meta-analysis for all outcomes using Freeman-Tukey double arcsine transformation and meta-regression for outcomes of interest were performed using the MAJOR tool (METAFOR package) through JAMOVI statistical Software and OpenMeta[Analyst] open source Statistical Software.

Results

Search results & baseline characteristics

After title-abstract and full-text screenings (Figure 1: PRISMA flow diagram), 1095 patients from 56 studies^{2–8,10–58} underwent EVT for intracranial artery dissections were included in this analysis (Table 1). The publication timeline of included studies 1999 to 2021. Intracranial VAD was reported in 1000 (86.8%) patients, and the rest (13.2%) located in the internal carotid artery (ICAD) (Table 2). Both VAD and ICAD patients presented at similar mean ages (50 years) with slight male predominance in the VAD population (57.8%, ICAD: 50.5%). Overall, nine (28.2%) of 37 unruptured ICAD patients presented with ischemic symptoms and 71 (79.4%) with subarachnoid hemorrhage. The ischemic presentation was reported in 12.7% of patients with VAD, and 67% were admitted with SAH. EVT-d was applied in 483 (46.2%) VAD and 5 (5.3%) ICAD patients. The vast majority of dissecting lesions receiving EVT-d were ruptured (86.6%, p < 0.05) and located in vertebral arteries 438/443 (98.8%, p = 0.074). EVT-r procedures included stent-assisted coiling (SAC) in 293 (45.3%), stenting in 280 (43.3%), flow diverters in 61 (9.4%), and sole coiling in only 9 (1.4%) patients. In patients receiving stenting, single stent was used for 135 (48.2%) and overlapping or multiple stents in 145 (51.8%).

Figure 1.

PRISMA flow diagram of the study selection process.

Table 1.

Details of included studies.

No	First Author	Year	Sample size	EVT-r	EVT-d
1	Ajay K Wakhloo	2008	21	21	0
2	B M Kim	2008	21	11	10
3	S Suzuki	2008	6	6	0
4	Yong Sam Shin	2007	10	10	0
5	J Y Ahn	2006	13	13	0
6	Felipe C Albuquerque	2005	23	2	21
7	Rene Anxionnat	2003	12	1	11
8	James D Rabinov	2003	26	0	26
9	H Manabe	2000	5	5	0
10	Tiffany Y So	2014	11	6	5
11	Ana Marcos Gonzalez	2014	10	9	1
12	Guilherme Dabus	2014	9	9	0
13	Reza Mohammadian	2013	17	3	14
14	Jian Wang	2013	11	9	2
15	T Nakazawa	2011	35	13	22
16	Yong Sam Shin	2012	12	3	9
17	George Kwok Chu Wong	2010	12	5	7
18	Won Ki Yoon	2010	22	22	0
19	Jong-Myong Lee	2010	25	2	23
20	S I Park	2009	29	29	0
21	Sang Hyun Suh	2009	11	11	0
22	Chuan-Chuan Wang	2017	38	38	0
23	Russell Cerejo	2017	7	7	0
24	K Urasyanandana	2017	11	5	6
25	Nishant Ganesh Kumar	2017	6	0	6
26	Yeongu Chung	2017	8	8	0
27	Hyoung Soo Byoun	2016	15	7	8
28	Thomas P Madaelil	2016	12	0	12
29	Anna Luisa Kuhn	2016	6	6	0
30	Dong Joon Kim	2015	5	5	0
31	S Mu	2016	21	21	0
32	Ying Song	2014	6	6	0
33	Yi-Bin Fang	2015	39	19	20
34	Kyoung Hyup Nam	2015	26	15	11
35	Kai-Jun Zhao	2014	97	97	0
36	Jiwei Zhang	2021	27	27	0
37	Gianmarco Bernava	2021	5	5	0
38	Zhongyin Ye	2021	8	8	0
39	Masanori Aihara	2021	12	12	0
40	Ching-Chang Chen	2021	12	12	0
41	Xiangjie Kong	2021	5	5	11
42	Lu Gao	2020	70	70	0
43	Yisen Zhang	2020	27	27	0
44	Cordell Baker	2020	9	9	0
45	Daniel M S Raper	2020	45	45	0
46	Xianli Lv	2020	5	5	0
47	Jun Kyeung Ko	2019	13	13	0
48	Sishi Xiang	2019	12	12	0
49	Stefan Schob	2019	7	7	9
50	S.-C. Jin	2009	42	9	33
51	I Yamaura	1999	6	0	6
52	Ichiro Yuki	2005	29	0	29
53	M Tsuura	1999	12	0	12
54	Chao-Bao Luo	2005	10	0	10
55	Yutaka Kai	2011	8	0	8
56	Daina Kashiwazaki	2013	73	0	73

Table 2.

Baseline characteristics.

Baseline characteristics	Intracranial ICAD	Intracranial VAD	P value*
N. (Only intervention)	95/1095 (13.2%)	1000/1095 (86.8%)
Mean age (range)	49.9 (31.2–64.8) /51	49.6 (28–63.8)/ 977	0.695
Gender (Female %)	49/119 (49.5%)	378/919 (42.2%)	0.337
Ischemic presentation	9/37 (28.2%)	83/658 (12.7%)	0.356
Hemorrhagic presentation	71/81 (79.4%)	575/896 (67%)	0.451
EVT-d	5/95 (5.3%)	483/1045 (46.2%)	0.074
EVT-r	90/95 (94.7%)	562/1045 (53.8%)	0.074

*T test for continuous and Chi square test was performed for categorical variables.

Reconstructive techniques

Six-hundred-forty-seven (59.1%) dissecting lesions received EVT-r; 49.8% were ruptured on initial presentation (Table 3). The intervention was successful in 92.6% of cases (586 out of 594). Procedural complications were experienced by 55 out of 607 patients [12.6% (95% CI (9.2%, 16.9%)] receiving EVT-r; 10.2% (95% CI 7.6%, 13.5%) had recurrent or de novo ischemic complaints and 7% (95% CI 5%, 9.7%) had recurrent or de novo bleeding. Delayed vasospasm was noted in 7 out of 90 patients [9.9% (95% CI 3.5%, 25%)]. Complete occlusion of EVT-r treated aneurysms was reported in 387 out of 596 aneurysms [70.9% (95% CI 61.2%, 79.1%)] at a 15.5-month-mean-follow-up. Twenty-three [9.3% (95% CI 6.4%, 13.2%)] aneurysms grew in size and 40 aneurysms [10.2% (95% CI (7.7%, 13.4%)] recurred on follow-up. Twenty-two (3.7%) out of 598 lesions demonstrated either partial or total occlusion of the parent artery. Good clinical outcomes were reported in 83.4% (95% CI 78.8, 87.2) patients and 91 out of 636 patients [14.7% (95% CI 10.3%, 20.5%)] had poor clinical outcomes. Overall mortality rate was 9.4% (95% CI 7.1%, 12.3%)].

Table 3.

Clinical and angiographic outcomes .

Outcomes	Overall % (95% CI), n/t	EVT-r % (95% CI), n/t,	EVT-d % (95% CI), n/t,	P value
N.	1095	647 (59.1%)	448 (40.9%)
Ruptured (%)	61.7, 646/1047	49.8, 271/544	86.6, 375/433	<.001
VAD (%)	86.8,1000/1095	86.2,562/652	98.8,438/443	0.074
Intervention success	92.3 (89.9, 94.2), 987/1005	92.6 (89.4, 94.9), 586/594	93.6 (89.6, 96.1), 401/411	0.298
Aneurysm complete occlusion	78.5 (71.9, 83.9), 720/966	70.9 (61.2, 79.1), 387/596	87 (82.7, 90.3), 333/370	0.001
Aneurysm growth	8.5 (6.1, 11.8), 25/503	9.3 (6.4, 13.2), 23/376	5.9 (2.7, 12.6), 2/127	0.347
Aneurysm recurrence	9.4 (7.4, 11.8), 53/977	10.2 (7.7, 13.4), 40/611	7.6 (4.9, 11.6), 13/366	0.075
Parent artery patency (%)	64.4, 580/901	96.3, 576/598	1.3, 4/303	<.001
Periprocedural complications	108 (11.1, 17.7), 108/974	12.6 (9.2, 16.9), 55/607	16.7 (11.5, 23.7), 53/367	0.157
Recurrent/De novo ischemia	11.2 (8.9, 14), 72/11.2	10.2 (7.6, 13.5), 34/633	12.8 (8.9, 18), 38/399	0.217
Recurrent/De novo hemorrhage	8.9 (6.9, 11.3), 50/1084	7 (5, 9.7), 20/647	9.4 (5.8, 14.8), 30/437	0.345
Delayed vasospasm	7.3 (3.5, 14.5), 9/185	9.9 (3.5, 25), 7/90	3.7 (1.3, 10.2), 2/95	0.320
Follow-up (months) (mean)	19 (16.4, 21.6), 946	15.5 (13.2, 17.7), 579	24.7 (16.2, 33.3), 367
mRS 0–2	79.9 (76.2, 83.2), 879/1066	83.4 (78.8, 87.2), 547/636	74.8 (69.3, 79.6), 332/430	0.002
mRS 3–5	14.3 (11.3, 17.9), 138/1066	14.7 (10.3, 20.5), 91/636	14.4 (11.1, 18.5), 47/430	0.502
Death	11.9 (9.9, 14.2), 88/1095	9.4 (7.1,12.3), 33/652	14.3 (11.3, 18.1), 55/443	<.001

CI: confidence interval; n/t: number of events out of the total sample.

EVT-r was associated with worse angiographic outcomes; lower rates of complete aneurysm occlusion but higher rates of parent artery patency in comparison with EVT-d (p < .05). More favorable clinical outcomes and lower mortality rates were observed in the EVT-r population (p < .05). We did not observe any statistical difference by applied EVT-r technique except for higher rate of recurrent/de novo hemorrhage with flow diverters (P = 0.02). Distribution of EVT-r techniques utilized for IAD management over the last two decades are illustrated in Figure 2.

Figure 2.

Scatterplots illustrate the distribution of EVT-r techniques; (A) stenting, (B) stent-assisted coiling, and (C) flow diverters utilized for management of IAD over the last two decades.

Deconstructive techniques

Four-hundred-forty-eight (40.9%) dissecting lesions received EVT-d; 86.6% were ruptured on initial presentation. The intervention was successfully applied in 401 (93.6%) out of 411 patients. Procedural complications were experienced by 53 out of 367 patients [16.9% (95% CI (11.5%, 23.7%)] receiving EVT-d; 12.8% (95% CI 8.9%, 23.7%) had recurrent or de novo ischemic complaints and 9.4% (95% CI 5.8%, 14.8%) had recurrent or de novo bleeding. Delayed vasospasm was noted in 2 out of 95 patients [3.7% (95% CI 1.3%, 10.2%)]. Complete occlusion of EVT-d treated aneurysms was reported in 333 out of 370 aneurysms [87% (95% CI 82.7%, 90.3%)] at a 24.7-month-mean-follow-up. Two [5.9% (95% CI 2.7%, 12.6%)] aneurysms showed growth in size and 13 [7.6% (95% CI (4.9%, 11.6%)] recurred. Four (1.3%) out of 303 occluded parent arteries reopened to blood circulation. Good clinical outcomes were reported in 74.8% (95% CI 69.3, 79.6) patients and 47 out of 430 patients [14.4% (95% CI 11.1%, 18%)] had poor clinical outcomes. Overall mortality rate was 14.3% (95% CI 11.3%, 18.1%)].

Ruptured dissecting aneurysms showed worse clinical outcomes and higher mortality rates compared to unruptured aneurysms. However, they demonstrated higher complete occlusion rates regardless of the applied EVT technique (p < .05). Most patients with ischemic unruptured dissections had poor clinical outcomes on the follow-up but with lower mortality rates (p < .05). The ischemic presentation was also significantly correlated with higher aneurysm growth rates. ICAD tended to grow in size and led to overall poor clinical outcomes (p < .05). Meta-regression results are available in table 4.

Table 4.

Meta-regression results.

Meta-regression results*		Hemorrhagic presentation (P)	Ischemic presentation (P)	VBJ (P)	SAC (EVT-r)	Stenting (EVT-r)	FD (EVT-r)
Intervention success	UV	0.601 (-)	0.517 ( + )	0.245 ( + )	0.957 (-)	0.451(-)	0.367 (-)
Intervention success	MV
Aneurysm complete occlusion	UV	0.01 ( + )	0.051 (-)	0.474 (-)	0.671 (-)	0.278 (-)	0.515 ( + )
Aneurysm complete occlusion	MV	0.002 ( + ) S^d ( + )
Aneurysm growth	UV	0.273 (-)	<0.001 ( + )	0.005 (-)	0.905 (-)	0.646 (-)	0.759 (-)
Aneurysm growth	MV		<0.001 ( + ) NS	0.013 (-) NS
Aneurysm recurrence	UV	0.267 (-)	0.607 ( + )	019 (-)	0.197 (-)	0.414 (-)	0.747 (-)
Aneurysm recurrence	MV
Periprocedural complications	UV	0.215 ( + )	0.324 (-)	0.413 (-)	0.687 (-)	0.161 (-)	0.060 ( + )
Periprocedural complications	MV
Recurrent/De novo ischemia	UV	0.512 ( + )	0.619 (-)	0.377 (-)	0.304 (-)	0.061 (-)	0.175 (-)
Recurrent/De novo ischemia	MV
Recurrent/De novo hemorrhage	UV	0.141 ( + )	0.324 (-)	0.142 (-)	0.098 ( + )	0.738 (-)	0.020 ( + )
Recurrent/De novo hemorrhage	MV
Delayed vasospasm	UV	0.76 (-)	0.649 ( + )	0.649 (-)	0.559 ( + )	0.806 (-)	0.578 ( + )
Delayed vasospasm	MV
mRS 0–2	UV	0.005 (-)	0.552 (-)	0.146 (-)	0.346 (-)	0.270 (-)	0.813 (-)
mRS 0–2	MV	<0.001 (-) S^d (-)
mRS 3–5	UV	0.208 ( + )	0.004 ( + )	<0.001 (-)	0.410 (-)	0.609 (-)	0.751 (-)
mRS 3–5	MV		0.436	0.002 (-) NS
Death	UV	0.009 ( + )	<0.001 (-)	0.792	0.858 (-)	0.721 (-)	0.327 (-)
Death	MV	0.006 ( + ) NS	<0.001 (-), S^d ( + )

*Multivariate multi-regression analysis to investigate the association between the hemorrhagic and ischemic presentation of intracranial VAD and ICAD along with used EVT technique and treatment outcomes.

P value represents the association between presentation characteristics and outcomes.

UV: univariate analysis; MV: multivariate analysis represents the association of both the corresponding variable and utilized endovascular technique with outcome of interest; NS: Non-significant; S^d: Significant for deconstructive treatments; ( + ): Positive correlation; (-): Negative correlation.

Discussion

Our meta-analysis of close to 1100 patients with IAD analyzed the efficacy and safety of emerging reconstructive and traditional deconstructive endovascular techniques based on the most recent literature. We found that EVT-d has been utilized primarily for VAD while ICAD has been predominantly managed with EVT-r. In comparison with EVT-d, EVT-r was associated with better clinical outcomes but worse angiographic outcomes with no difference in periprocedural complications. Ruptured dissections were a major cause of unfavorable clinical outcomes and mortality. Patients with ischemic presentation experienced more disability and poorer clinical outcomes (mRS 3–5) but less mortality.

Conservative management of asymptomatic dissections is preferred.¹ Symptomatic IAD represents a clinical entity of significant challenge for treating clinicians due to its poor clinical outcomes and limited medical and interventional treatments. Previous studies reported surgical sacrifice of the dissected vessels. In selective cases, revascularization via bypass was performed to treat symptomatic IAD.⁵⁹ Endovascular treatments of IAD have been introduced in the last two decades, which have evolved from simple coiling or balloon occlusion for parent artery sacrifice to more selective and sophisticated reconstructive modalities including overlapping stenting, stent-assisted coiling, and flow diverters.^{3,5,11,13,17,20,43} IAD mostly affects the vertebral arteries and rarely the internal carotid arteries. Deconstructive treatments were utilized commonly for vertebrobasilar dissections with good angiographic outcomes, as reported in a previous meta-analysis.⁹ Although the authors reported no statistical difference in clinical outcomes between both techniques, our updated study showed worse clinical outcomes and higher mortality rates with EVT-d. The vast majority of dissecting aneurysms managed with EVT-d were ruptured on presentation, potentially explaining more unfavorable clinical outcomes with this approach.

Similar to the previous study, we demonstrated better angiographic outcomes (dissecting aneurysm occlusion) with EVT-d. However, complete occlusion of the parent vessel does not necessarily correlate with better clinical outcomes or lower rebleeding rates. De novo/recurrent hemorrhage and stroke rates were low in EVT-d and EVT-r. Furthermore, aneurysm recurrence rates showed no significant discrepancy between both techniques. New endovascular techniques such as overlapping stents, stent-assisted coiling and flow diverters, have been introduced in the last 2 decades and often applied in IAD management. Such techniques have demonstrated excellent angiographic outcomes with preservation of blood flow within the dissected vessel, eliminating potential ischemic events. Hyun Suh et al. reported excellent clinical outcomes in 91% and complete occlusion in 90% of dissecting aneurysms receiving stent-assisted coil embolization.⁴³ Natarjan et al. published a series of 12 patients with VAD who underwent flow diverter embolization and demonstrated promising clinical outcomes in 91.7% and complete occlusion in all patients.⁶⁰ However, other studies reported modest clinical and angiographic outcomes following those techniques.^5,47 We did not observe a noteworthy difference among these techniques in our meta-analysis. High-quality, uniform, and adequately powered studies with these novel EVT-r techniques are needed as 1) they have been very recently implemented in the treatment of IAD, 2) experience from various institutions are heterogeneous, and 3) published cohorts are small in size. These factors are significant limitations to generalizing these findings.

Anterior circulation dissections are rare and affect mainly the ICA.⁶¹ Expectedly, the natural history of ICAD is significantly different from VAD; however, the different pathogenesis underlying ICAD and VAD is not quietly understood.⁶² No statistically significant difference was found in baseline characteristics between ICAD and VAD in our study. However, in terms of management and outcomes, ICAD received primarily reconstructive treatments and often recurred/grew at follow-up. Patients with ICAD had overall poorer clinical outcomes than VAD, which had better clinical outcomes. Nevertheless, no difference in rates of procedural complications or mortality was observed. Despite the small sample size of ICAD limiting the validity of our findings, the existing data suggest that ICAD can be managed with EVT-r. Finally, EVT-d of ICAD can be detrimental and lead to major ischemic infarcts due to a much larger territory supplied by ICA (∼80% of the ipsilateral hemisphere), thus increasing mortality (malignant ischemic infarcts and herniation). Therefore, EVT-d should be only reserved for patients with ruptured ICAD and major SAH who tolerate balloon occlusion test Furthermore, integrating novel reconstructive techniques in endovascular neurosurgery training and practice is required.

Limitations

The main limitation of this meta-analysis is most studies included in our analysis are retrospective case series with a small sample size. Our meta-analysis suffers considerable heterogeneity due to the variety in evaluation and treatment protocols among institutions and dissection characteristics. We could not perform regression analyses for the clinical and angiographic outcomes based on baseline dissection characteristics (ruptured vs. unruptured, etc.) as most studies lacked this information at an individual level.

Conclusion

IAD is a unique entity affecting mostly the vertebral artery and rarely the internal carotid arteries. EVT-d has been utilized previously to obliterate VAD, while ICAD is managed mainly with reconstructive techniques. VAD typically has often good clinical outcomes after endovascular treatments. The most recent literature evidence, represented by our study, demonstrates the less favorable clinical outcomes of EVT-d. Our findings suggest that EVT-d should be reserved for selected cases, and novel EVT-r modalities should be more readily implemented and integrated into endovascular training and practice. Finally, an adequately powered, multi-center, randomized clinical trial with comparative analysis of deconstructive and reconstructive endovascular techniques for IAD management is warranted to validate our results.

Footnotes

Acknowledgements

The authors acknowledge Karl Holub, Stephen Mead, Jeffrey Johnson, and Darian Lehmann-Plantenberg for their design, development, and support of the Nested Knowledge meta-analytical software.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Muhammed Amir Essibayi

Abbreviations

References

Kim

, et al. Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection. Neurology 2011; 76: 1735–1741.

Kai

Nishi

Watanabe

, et al. Strategy for treating unruptured vertebral artery dissecting aneurysms. Neurosurgery 2011; 69: 1085–1091. discussion 1091–1092.

Kashiwazaki

Ushikoshi

Asano

, et al. Long-term clinical and radiological results of endovascular internal trapping in vertebral artery dissection. Neuroradiology 2013; 55: 201–206.

Anxionnat

de Melo Neto

Bracard

, et al. Treatment of hemorrhagic intracranial dissections. Neurosurgery 2003; 53: 289–300. discussion 300–301.

Cerejo

Bain

Moore

, et al. Flow diverter treatment of intracranial vertebral artery dissecting pseudoaneurysms. J Neurointerv Surg 2017; 9: 1064–1068.

Gonzalez

Narata

Yilmaz

, et al. Blood blister-like aneurysms: single center experience and systematic literature review. Eur J Radiol 2014; 83: 197–205.

Kühn

Kan

Massari

, et al. Endovascular reconstruction of unruptured intradural vertebral artery dissecting aneurysms with the Pipeline embolization device. J Neurointerv Surg 2016; 8: 1048–1051.

Nam

Cha

, et al. Endovascular treatment of acute intracranial vertebral artery dissection: long-term follow-up results of internal trapping and reconstructive treatment using coils and stents. J Neurointerv Surg 2015; 7: 829–834.

Sönmez

Brinjikji

Murad

, et al. Deconstructive and reconstructive techniques in treatment of vertebrobasilar dissecting aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol 2015; 36: 1293–1298.

10.

Ahn

Han

Kim

, et al. Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling. AJNR Am J Neuroradiol 2006; 27: 1514–1520.

11.

Aihara

Shimizu

Naito

, et al. Endovascular treatment strategy and clinical outcomes for ruptured blood blister-like aneurysms of the internal carotid artery using low-profile visualized intraluminal support stent. World Neurosurg 2021; 149: e146–e153.

12.

Albuquerque

Fiorella

Han

, et al. Endovascular management of intracranial vertebral artery dissecting aneurysms. Neurosurg Focus 2005; 18: E3.

13.

Baker

Grandhi

Griessenauer

, et al.

Pipeline embolization in patients with posterior circulation subarachnoid hemorrhages: is takotsubo cardiomyopathy a limiting factor?

World Neurosurg 2020; 143: e523–e528.

14.

Bernava

Meling

Rosi

, et al. Acute stenting and concomitant tirofiban administration for the endovascular treatment of acute ischemic stroke related to intracranial artery dissections: a single center experience and systematic review of the literature. J Stroke Cerebrovasc Dis 2021; 30: 105891.

15.

Byoun

Choi

, et al. Comparison of endovascular treatments of ruptured dissecting aneurysms of the intracranial internal carotid artery and vertebral artery with a review of the literature. J Korean Neurosurg Soc 2016; 59: 449–457.

16.

Chen

C-C

Chen

C-T

Huang

Y-H

, et al. Modified balloon-in-stent technique for circumferential vertebral artery dissecting aneurysm. World Neurosurg 2021; 147: e552–e558.

17.

Chung

Lee

Choi

, et al. Triple stent therapy for the treatment of vertebral dissecting aneurysms: efficacy and safety. World Neurosurg 2017; 99: 79–88.

18.

Dabus

Lin

Linfante

. Endovascular treatment of fusiform intracranial vertebral artery aneurysms using reconstructive techniques. J Neurointerv Surg 2014; 6: 589–594.

19.

Fang

Y-B

Zhao

K-J

Y-N

, et al.

Treatment of ruptured vertebral artery dissecting aneurysms distal to the posterior inferior cerebellar artery: stenting or trapping?

Cardiovasc Intervent Radiol 2015; 38: 592–599.

20.

Ganesh Kumar

Ladner

Kahn

, et al. Parent vessel occlusion for treatment of cerebral aneurysms: is there still an indication? A series of 17 patients. J Neurol Sci 2017; 372: 250–255.

21.

Gao

Qian

Luo

, et al. Clinical efficacy and quality of life follow-up of reconstructive endovascular therapy for acute intracranial vertebral artery dissection aneurysms. Front Surg 2020; 7: 32.

22.

Jin

S-C

Kwon

Choi

C-G

, et al. Endovascular strategies for vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 2009; 30: 1518–1523.

23.

Kim

Suh

Park

, et al. Management and clinical outcome of acute basilar artery dissection. AJNR Am J Neuroradiol 2008; 29: 1937–1941.

24.

Kim

Suh

, et al. Self-expanding stent placement for anterior circulation intracranial artery dissection presenting with ischemic symptoms. Neurosurgery 2015; 76: 158–164. discussion 164.

25.

Kong

Sun

Ling

, et al. Endovascular treatment for ruptured vertebral dissecting aneurysms involving PICA: reconstruction or deconstruction? Experience from 16 patients. Interv Neuroradiol 2021; 27: 163–171.

26.

Kyeung Ko

Weon Lee

Hwa Choi

, et al. Endovascular reconstructive treatment using a fill-and-tunnel technique for a fusiform vertebral artery dissecting aneurysm with ipsilateral dominance. Interv Neuroradiol 2019; 25: 539–547.

27.

Lee

J-M

Kim

T-S

Joo

S-P

, et al. Endovascular treatment of ruptured dissecting vertebral artery aneurysms--long-term follow-up results, benefits of early embolization, and predictors of outcome. Acta Neurochir (Wien) 2010; 152: 1455–1465.

28.

Luo

C-B

Chang

C-Y

Teng

MM-H

, et al. Endovascular treatment of ruptured vertebral dissecting aneurysms with electrodetachable coils. J Chin Med Assoc 2005; 68: 578–584.

29.

Zhang

, et al. Acute hemorrhagic cerebral artery dissection: characteristics and endovascular treatment. Neuroradiol J 2020; 33: 112–117.

30.

Madaelil

Wallace

Chatterjee

, et al. Endovascular parent vessel sacrifice in ruptured dissecting vertebral and posterior inferior cerebellar artery aneurysms: clinical outcomes and review of the literature. J Neurointerv Surg 2016; 8: 796–801.

31.

Manabe

Hatayama

Hasegawa

, et al. Coil embolisation for ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery. Neuroradiology 2000; 42: 384–387.

32.

Mohammadian

Taheraghdam

Sharifipour

, et al. Endovascular treatment of intracranial artery dissection: clinical and angiographic follow-up. Neurol Res Int 2013; 2013: 968380.

33.

Yang

, et al. Reconstructive endovascular treatment of spontaneous symptomatic large or giant vertebrobasilar dissecting aneurysms: clinical and angiographic outcomes. Clin Neuroradiol 2016; 26: 291–300.

34.

Nakazawa

Takeichi

Yokoi

, et al. Treatment of spontaneous intradural vertebral artery dissections. Neuroradiol J 2011; 24: 699–711.

35.

Park

Kim

, et al. Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 2009; 30: 1351–1356.

36.

Rabinov

Hellinger

Morris

, et al. Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 2003; 24: 1421–1428.

37.

Raper

DMS

Caldwell

Brew

, et al. A comparison of endovascular strategies in the treatment of ruptured vertebral artery aneurysms. J Clin Neurosci 2020; 75: 168–175.

38.

Schob

Becher

Bhogal

, et al. Segment occlusion vs. Reconstruction-A single center experience with endovascular strategies for ruptured vertebrobasilar dissecting aneurysms. Front Neurol 2019; 10: 207.

39.

Shin

Kim

S-H

, et al. Endovascular treatment of bilateral intracranial vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage. Neurosurgery 2012; 70: 75–81. discussion 81.

40.

Shin

Kim

. Stenting for vertebrobasilar dissection: a possible treatment option for nonhemorrhagic vertebrobasilar dissection. Neuroradiology 2007; 49: 149–156.

41.

Mitchell

Dowling

, et al. Efficacy, complications and clinical outcome of endovascular treatment for intracranial intradural arterial dissections. Clin Neurol Neurosurg 2014; 117: 6–11.

42.

Song

Wang

, et al. Retreatment and outcomes of recurrent intracranial vertebral artery dissecting aneurysms after stent assisted coiling: a single center experience. PLoS One 2014; 9: e113027.

43.

Suh

Kim

Park

, 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 2009; 111: 48–52.

44.

Suzuki

Kurata

Iwamoto

, et al. Endovascular surgery using stents for vertebral artery dissecting aneurysms and a review of the literature. Minim Invasive Neurosurg 2008; 51: 193–198.

45.

Tsuura

Terada

Yokote

, et al. Endovascular treatment for vertebral dissecting aneurysm presenting with subarachnoid hemorrhage. Interv Neuroradiol 1999; 5: 203–206.

46.

Urasyanandana

Withayasuk

Songsaeng

, et al. Ruptured intracranial vertebral artery dissecting aneurysms: an evaluation of prognostic factors of treatment outcome. Interv Neuroradiol 2017; 23: 240–248.

47.

Wakhloo

Mandell

Gounis

, et al. Stent-Assisted reconstructive endovascular repair of cranial fusiform atherosclerotic and dissecting aneurysms: long-term clinical and angiographic follow-up. Stroke 2008; 39: 3288–3296.

48.

Wang

C-C

Fang

Y-B

Zhang

, et al. Reconstructive endovascular treatment of vertebral artery dissecting aneurysms with the low-profile visualized intraluminal support (LVIS) device. PLoS One 2017; 12: e0180079.

49.

Wang

Sun

Bao

, et al. Endovascular management of vertebrobasilar artery dissecting aneurysms. Turk Neurosurg 2013; 23: 323–328.

50.

Wong

GKC

Tang

Poon

, et al. Treatment of ruptured intracranial dissecting aneurysms in Hong Kong. Surg Neurol Int 2010; 1: 84.

51.

Xiang

, et al. Reconstructive endovascular treatment of the V4 segment of a vertebral artery dissecting aneurysm with the Willis covered stent: a retrospective study. Interv Neuroradiol 2019; 25: 548–555.

52.

Yamaura

Tani

Yokota

, et al. Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Guglielmi detachable coils. J Neurosurg 1999; 90: 853–856.

53.

. The formation mechanism of acute dissection of blood blister-like aneurysm and its implication of endovascular treatment. Chin Neurosurg J 2021; 7: 32.

54.

Yoon

Kim

S-R

, et al. Angiographic and clinical outcomes of stent-alone treatment for spontaneous vertebrobasilar dissecting aneurysm. Acta Neurochir (Wien) 2010; 152: 1477–1486. discussion 1486.

55.

Yuki

Murayama

Viñuela

. Endovascular management of dissecting vertebrobasilar artery aneurysms in patients presenting with acute subarachnoid hemorrhage. J Neurosurg 2005; 103: 649–655.

56.

Zhang

. Endovascular treatment of blood blister-like aneurysms of internal carotid artery: stent-assisted coiling and pipeline flow diversion. J Clin Neurosci 2021; 90: 8–13.

57.

Zhang

Tian

Zhu

, et al. Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10-year neurointerventional experience. Stroke Vasc Neurol 2020; 5: 291–301.

58.

Zhao

K-J

Zhao

Huang

Q-H

, et al. The interaction between stent(s) implantation, PICA involvement, and immediate occlusion degree affect symptomatic intracranial spontaneous vertebral artery dissection aneurysm (sis-VADA) recurrence after reconstructive treatment with stent(s)-assisted coiling. Eur Radiol 2014; 24: 2088–2096.

59.

Frisoli

Srinivasan

Catapano

, et al. Vertebrobasilar dissecting aneurysms: microsurgical management in 42 patients. J Neurosurg 2021: 1–9. doi:10.3171/2021.9.JNS21397

60.

Natarajan

Lin

Sonig

, et al. The safety of Pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center. J Neurosurg 2016; 125: 111–119.

61.

Ohkuma

Suzuki

Ogane

. Dissecting aneurysms of intracranial carotid circulation. Stroke 2002; 33: 941–947.

62.

Debette

Grond-Ginsbach

Bodenant

, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology 2011; 77: 1174–1181.