1. Spontaneous dissection of intradural vertebral and basilar arteries. Review of 55 cases regarding clinical presentation, morphology and multimodality endovascular approaches Piske, Ronie Leo PhD, MD; Silva, José Laercio MD; Baccin, Carlos Eduardo MD CNA – Centro de Neuroangiografia Hospital Beneficência Portuguesa de São Paulo – Brazil roniepiske@uol.com.br XIX Symposium Neuroradiologicum The World Congress of Diagnostic & Therapeutic Neuroradiology Bologna, Italy - 4-9 October 2010

2. Arterial dissection: Is the disruption of the layers of the arterial wall Sub intimal: reach the internal layers of the artery wall, - headache, neck pain and or ischemic stroke Adventicial: rupture of all layers of the artery wall. - SAH Endo S et al. Neurosurgery 33:732-738, 1993. Courtesy of In Sup CHOI/2001

3. Ischemic type Double lumenString and pear

4. Fusiform aneurysm

5. Saccular aneurysms

6. Saccular aneurysm Hemorrhagic type

7. hemorrhagicischemic n2827 saccular an157 fusiform1311 double lumen41 stenosis29 occlusion15 thrombus (MRI)17 + 1 artery51 Review of 55 cases from 1996 to 2008

8. Hemorrhagic n = 28 Ischemic n = 27 female167 male1220 age range33-74yo11-70yo age (medium)50yo49yo

9. Hemorrhagic Type n=28 Ischecmic Type n=21 No stroke group Prodroms 10 cases n=5 2,3,3,7,7 days n=5 1,3,7,10,15 days n=6 New disseccion (other vessel) 1 (PCoA-SAH)1:opposite Vertebral artery- SAH New event (same vessel) 6 (21%)1(4,7%) Review of 55 cases from 1996 to 2008 No evolution from ischemic to hemorrhagic

10. Review of 55 cases from 1996 to 2008 Symptoms at presentation: 23 – SAH 16 – ischemic stroke 16 – headache/neck pain

11. Review of 55 cases from 1996 to 2008 Symptoms at presentation: 23 – SAH 16 – ischemic stroke 16 – headache/neck pain up to 7days 5 SAH up to 15 days 5 ischemic stroke 6 rebled hs up to 19 days 6 no stroke 1new ischemia

12. Review of 55 cases from 1996 to 2008 Acute installation of symptoms Unstable period after the beginning of the symptoms (up to 20-30days) bled, infarct, rebleeding… Stable period after one month (spontaneous cure) There is 3 periods in the disease process:

13. April 18, 2008September 1rst, 2008

14. Vertebral – 25 patients Basilar – 3 patients Bilateral – 2 patients Hemorrhagic group – 28 patients Fisher I – 2 II – 1 III – 6 IV – 16 NA: 3 In the ictus: Coma: 5 CRA: 2 Deficit: 3 Pulmonar edema: 1 Vasospasm: 7 patients (25%) 1 died 6 rebleeding: 13hs to 19 days 1 - 10d after embo 3 died 2 dependent 1 normal

15. Iocal ischemia (MRI) – 7 distal Isquemia (MRI) – 2 Cranial nervf palsy – 5 Deficit without ischemia at MRI – 7 No ischemic symptoms – 6 Ischemic group – 27 patients Vertebral – 25 Basilar – 2 Bilateral – 2 PICA involved – 3 (bilateral in 2) New ischemia – 1 New dissection – 1 (contra-lateral, with SAH)

16. Endovascular treatment Depends of the anatomia: Hipoplasia Vasospasmo PICA ASA Should be done immediatelly * P. Mercier, G. Brassier

17. Proximal occlusion Proximal + aneurysm occlusion Trapping Stent+coils

18. Hemorrhagic n=28 cureIschemic n=27 cureTotal n=55 n/(cure) Proximal occlusion 32548(6) Proximal+ aneurysm occlusion 11223(3) Trapping992211(11) Stent+coils716013(1) Total201315835(21)

20. Control months after

21. Proximal occlusion - and distal occlusion 12hs after SAH

23. Female 60 yo, Fisher IV, coma

25. Rebleeding 10 days after

27. 1 month after

28. conclusions 3 different types : hemorrhagic, ischemic and no stroke Unstable early phase – unpredictable evolution (prodroms) Treatment should be made immediately Although morphology may be similar, some angiographic aspects are more frequent in some groups Deconstructive techniques are safe and efficient Reconstructive techniques may protect (not always) against rebleeding and give time to enter in a stable phase. Cure is rare

29. Thank you