A comparison of endovascular strategies in the treatment of ruptured vertebral artery aneurysms

•Ruptured vertebral artery dissecting aneurysms are challenging to treat.•Endovascular trapping of the diseased segment is generally safe, even involving the PICA origin.•Outcomes are similar for proximal parent vessel occlusion and trapping.•Understanding the vertebrobasilar anatomy is critical in patient selection for VADA treatment. Contemporary management of ruptured vertebral artery dissecting aneurysms (VADA) has evolved beyond proximal parent artery occlusion (PPAO) to include endovascular trapping (ET) of the diseased segment and vessel preserving stent treatments. The aim of this retrospective cohort study was to assess the outcomes of patients with ruptured VADAs who underwent endovascular management with trapping of the diseased segment as the first-line treatment approach. We evaluated an institutional database of patients with ruptured VADAs who were treated at Auckland City Hospital from 1998 to 2017. Baseline and outcomes data were analyzed. High-grade SAH was defined as a World Federation of Neurological Surgeons or a Hunt and Hess grade of IV-V. Favorable outcome was defined as a modified Rankin Scale of 0–2. The study cohort was comprised of 45 ruptured VADA patients with a mean age of 50 years. The mean follow-up duration was 12.9 months. ET of the diseased segment was performed in 32 cases (71.1%), PPAO of the VA was performed in 12 cases (26.7%) and reconstruction using a flow diverting stent was performed in 1 case (2.2%). The overall procedural complication rate was 13%, including procedural neurological morbidity in 4.4%. At last follow-up, no further aneurysm filling was seen in any case, and 77.8% had a favorable outcome. ET affords a favorable risk to benefit profile for patients with ruptured VADAs. ET remains a reasonable option for ruptured VADAs in patients with sufficient collateral supply to the vertebrobasilar system.