Outcomes Following Surgical and Endovascular Treatment of Extracranial Vertebral Artery Aneurysms (VAA): A Systematic Evaluation of the Literature

doi:10.21203/rs.3.rs-2562026/v1

Download PDF

Research Article

Outcomes Following Surgical and Endovascular Treatment of Extracranial Vertebral Artery Aneurysms (VAA): A Systematic Evaluation of the Literature

https://doi.org/10.21203/rs.3.rs-2562026/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 02 Oct, 2023

Read the published version in Neurosurgical Review →

You are reading this latest preprint version

Introduction:

Extracranial vertebral artery aneurysms are rare complications from trauma and multiple diseases. However, the difference between clinical and surgical profiles is not well understood.

Objective

To investigate the clinical and interventional outcomes following extracranial vertebral artery aneurysms (VAA) treatment through a systematic review of the literature to date.

Methods

An electronic database search for full-text English articles was conducted following PRISMA guidelines. The search yielded results on clinical and surgical outcomes for extracranial VAAs. These results included patient-specific risk factors, indications, and techniques.

Results

Our literature search yielded 561 articles, of which 36 studies were qualified to be included in the analysis. A total of 55 patients with multiple various extracranial VAA incidents were included. The mean age of subjects was 42 years (ranging from 13 to 76 years), and most patients were males (71%, n = 39). Blunt trauma was the most frequent risk factor for extracranial VAA formation (35%, n = 19). The majority of aneurysms (60%) were dissecting in nature. The most common form of treatment for extracranial VAAs was a flow diverter (24%, n = 13). Overall, five (9%) patients had long-term adverse neurological complications following intervention with 5% (n = 3) mortality, 2% (n = 1) resulting in unilateral vocal cord paralysis, and 2% (n = 1) resulting in a positive Romberg sign. The mortality rate is 15.7% in the surgical group, whereas the endovascular treatment did not result in any mortality.

Conclusion

The endovascular approach is a safe and effective treatment of extracranial VAAs due to its relatively low overall complication rate and lack of resulting mortality. This contrasts with the surgical approach, which results in a higher rate of complications, recurrence, and mortality outcomes. An understanding of the factors and clinical outcomes associated with the incidence of extracranial VAAs is essential for the future improvement of patient outcomes.

Strokes of the posterior circulation account for 20–25% of all ischemic strokes. They may arise from vertebral artery aneurysms within the intracranial segment.¹The incidence of associated extracranial vertebral artery dissections and pseudoaneurysms is rare, representing less than 1% of supra-aortic aneurysms.² Vertebral artery aneurysms may lead to local nerve compression when located outside the intracranial segment. If they rupture, excessive bleeding may be fatal. Extracranial vertebral artery aneurysms (VAAs) may present as either true aneurysms, false aneurysms, or dissecting aneurysms. Furthermore, VAAs frequently occur on the V1 and V3 segments.³ The primary etiology of an extracranial VAA is penetrating neck trauma. It can also occur secondary to dissection, blunt trauma, atherosclerosis, infection, connective tissue disease, or iatrogenic trauma due to craniocervical fusions.⁴

Small lesions may be asymptomatic or be incidental findings, whereas larger lesions may manifest with neurologic symptoms and deficits. These deficits may include radiculopathy, myelopathy, or brain stem compression, depending on the lesion's size and location. More adverse complications include subarachnoid hemorrhage and spontaneous thrombosis with or without associated peripheral cerebrovascular incidents or rupture.⁵ Management has evolved throughout the last 20 years and primarily features endovascular techniques assisted by balloons that can be used in coiling and testing parent vessel occlusion before sacrifice. Opposed to standard microsurgical clipping that can be used to reconstruct the neck of a complex aneurysm, allowing successful placement of coils across a narrow neck.⁶ Additional surgical treatments, such as vertebral artery bypasses and ligations, may also be performed to treat extracranial VAAs. The evolution of treatments for extracranial VAAs may have altered patient outcomes of these rare aneurysms. While studies are exploring treatments for intracranial vertebral aneurysms, few have comprehensively evaluated treatments and outcomes for extracranial VAAs.⁷

The present study retrospectively reviewed the literature on extracranial VAAs to analyze the effectiveness of treatments and display the various complications associated with interventions. Given the rarity of extracranial VAAs, this study aimed to explore the presentation, treatment management, and complications across the literature about its modern management.

Search Strategy

A systematic review of literature discussing the overall outcomes of extracranial VAAs was performed. The literature search and screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines (PRISMA).⁸ A comprehensive search of several databases from each database's inception to June 10th, 2022, in English language, was conducted. The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced librarian with input from the study's principal investigator. Controlled vocabulary supplemented with keywords was used to search for surgical and endovascular treatment of extracranial VAAs in adult patients. The actual strategy listing all search terms used and how they are combined is available in the appendix. We searched Pubmed, Embase, and Web of Science for search terms such as “extracranial vertebral artery aneurysm,” “vertebral artery traumatic pseudoaneurysm,” “flow-diverting stent,” “iatrogenic extracranial pseudoaneurysm,” and “intravascular stent” alone or in combination with one another (Fig. 1).

Selection Criteria

Inclusion criteria were provided in the English language, provided description and outcome of at least one patient with a verified extracranial vertebral artery aneurysm, the extracranial vertebral aneurysm was confirmed as either true or false (pseudo), and the outcomes of the procedures were provided. The exclusion criteria comprised non-English text, non-human studies, and studies that did not report outcomes. Throughout the study, an adverse outcome was defined as any treatment outcome that caused a long-term disability, prolonged hospitalization after the initial treatment, or death.

Data Extraction and Statistical Analysis

The following variables were abstracted from the included studies: the number of patients; patient demographics including age and gender; follow-up angiographic and clinical time; aneurysm morphology including saccular, dissecting, fusiform, and blister; aneurysm location and size; type of intervention including flow diversion (FD), overlapping stents, coil embolization, stent-assisted coiling, liquid embolization with onyx and coil embolization, balloon-expandable stent and coils, vertebral ligation, and vertebral bypass; intervention-related complications including peri-procedural hemorrhage, vocal cord paralysis, and instability. Continuous variables were presented as mean/median. Categorical variables were presented as frequency and percentages.

Our literature search yielded 289 articles, of which 65 studies qualified to be included in the systematic review. Additional information related to the study selection and exclusion steps is summarized in (Fig. 1).

Description of Studies

Sixty-five retrospective descriptive case series was included in our review with a total of 84 patients, all of whom underwent endovascular or surgical procedures for 90 total extracranial VAA treatments. The mean age of subjects was 41.9 years (ranging from 13 to 76 years), and the majority of patients were males (65%, n = 55)^4,9–72 (Table 1). The most reported aneurysm morphology was dissecting (50%, n = 35), followed by saccular (30%, n = 21) (Table 1). Most reported extracranial vertebral aneurysmal locations were on the left vertebral artery (61.1%, n = 52) at the V2 segment (39.1%, n = 36). There was a total of 63 reported pseudoaneurysms representing 70% of all total aneurysms. Six patients (7.14%) presented with a subarachnoid hemorrhage before treatment. Most patients underwent endovascular intervention (65.4%, n = 53) vs. surgical intervention (34.6%, n = 28). A majority of surgeons preferred to utilize vertebral artery preservation (60.4%, n = 49) techniques as compared to vertebral artery sacrificial techniques (39.5%, n = 32) when treating the aneurysm (Table 3).

Table 1

Pooled Demographic Data of Extracranial Vertebral Artery Population
Type of Study	Total No. of Patient(s)	Mean Age	Gender	Side of VA aneurysms	Vertebral Arterial Aneurysmal Location	Pseudoaneurysm Presence	Etiology	Clinical Symptom(s)	Patient Medical History	Aneurysm Morphology
65 Retrospective Case Series	84	41.9	Males = 55 Females = 29	Right = 33 Left = 52	V1 = 24 V2 = 36 V3 = 28 V4 = 4	Yes = 63 No = 27	Penetrating Trauma = 18 Primary Disorder*=15 Unknown = 19 Blunt Trauma = 22 Iatrogenic = 2	Neck Pain = 19 Enlarging Mass = 14 Traumatic Incident = 11 Headache = 6 Radiculopathy = 5 Other = 15	Diabetes = 2 Hypertension = 6 Recent Neck Trauma = 22 Smoking = 1	Saccular = 21 Dissecting = 35 Fusiform = 9 Blister = 5
*=Primary disorders include Rheumatoid Arthritis Vasculitis, Neurofibromatosis, Ehlers Danlos Syndrome

Table 2-Pooled Outcomes Data of Extracranial Vertebral Artery Population

Type of Intervention (Surgical or Endovascular)

Type of Specific Surgical or Endovascular Procedures

Vertebral Artery Sacrifice or Preservation Treatment Technique

Complications

Overall Postoperative or Procedural Complete Extracranial VAA Occlusion Rate (%)

Rate of Patients That Had Completely Resolved Initial Symptoms by Final Follow Up (%)

Overall Mortality Rate (%)

Surgical=28

Endovascular=53

Other=4

Flow Diverter= 13

Overlapping Stents= 5

Coil Embolization= 15

Stent-assisted coiling= 4

Liquid embolization with onyx and coil embolization= 1

Balloon expandable stent and coils= 15

Vertebral Ligation= 16

VA Bypass= 12

Preservation= 47

Sacrifice= 30

Periprocedural hemorrhage=3

Periprocedural ischemic stroke=3

Delayed ischemic stroke=1

Delayed Stent Stenosis=1

Other=7

3.6

Table 3

Pooled Clinical and Angiographic Outcomes of Extracranial Vertebral Artery Patients Treated Endovascularly and Surgically
Outcome	n	%
Endovascular-Related Complications	9/58 Vessels	15.5
Endovascular-Related Mortality	0/53 Patients	0
Surgically-Related Complications	9/28 Vessels	32
Surgically-Related Mortality	3/28 Patients	10.7
Pseudoaneurysms successfully occluded after initial intervention	47/52 Vessels	90.4
Development of Negative Neurological Outcomes post initial intervention	6/84 Patients	7.1
Complications related to Vertebral artery Sacrificial treatment	7/30 Patients	23
Complications related to Vertebral artery Preservational treatment	11/47 Patients	23
Mortality related to Vertebral artery Sacrificial treatment	3/30 Patients	10
Mortality related to Vertebral artery Perservational treatment	0/47 Patients	0

Abbreviations: N=Number of Patients or Vessels, %=Percentage

Overall, 69 patients (82.1%) received a follow-up angiographic evaluation with an average angiographic follow-up time of 14.97 months and an average clinical follow-up time of 17.85 months. At the last follow-up, the average overall mRS clinical outcome score was 0.46 among all patients (mRS scale is 0–6 with 0 = no postoperative deficits and 6 = death).

Regarding interventional complications, peri-procedural hemorrhage, and ischemic stroke were both the most common complications (40%, n = 6/15); two of these patients resulted in death soon after that (Table 3). Most of the aneurysms with follow-up angiography were occluded entirely (87%), and 10.3% displayed residual aneurysms with no further management. The rate of endovascular-related complications (15.5%, n = 9/58 vessels) was lower than the rate of surgically related complications (32%, n = 9/28 vessels) (Table 3). The rate of endovascular-related mortality (0%, 0/53 patients) was lower than the rate of surgically related mortality (10.7%, 3/28 patients). A high rate of reported pseudoaneurysms successfully occluded after the initial surgical or endovascular intervention (90.4%, 47/52 vessels). Most patients had their initial symptoms entirely resolved (86.4%, n = 70) following the final surgical or endovascular treatment. Development of new neurological symptoms after the initial endovascular or surgical intervention was 7.1% (6/84 patients), of which 67% were after surgical intervention. The reintervention rate consisted of two patients (2.4%, n = 2/84), one of which underwent intraoperative unilateral intraoperative vertebral artery ligation after a failed vertebral bypass,⁶⁵ and the other because of a post-intervention ischemic stroke,⁶⁹ which was resolved by utilizing a different endovascular approach. This led to a complete occlusion after the stroke was resolved, but several residual symptoms were noted, including bilateral right visual defects, color blindness, and difficulty with memory. Both resulted in complete aneurysmal occlusion after the revised intervention. Patients with a dissecting aneurysm morphology tended to have more complications after treatment compared to other aneurysm morphologies, with 22.8% resulting in a neurological complication/deficit or recurrence. The remaining aneurysm morphologies (saccular, fusiform, and blister) presented with post-neurological complications/deficits or recurrence in some instances.

Treatment Interventions of Extracranial VAAs

The endovascular and surgical treatments utilized to manage extracranial VAAs varied throughout the studies (Table 2). There was a total of five types of endovascular procedures used to treat the extracranial VAAs, including flow diversion (pipeline embolization device alone, flow diverter + coil, permanent metal wire stents), overlapping stents, coil embolization, stent-assisted coiling, liquid embolization with onyx, and coil embolization (Table 2). Two surgical techniques were used to treat extracranial vertebral artery aneurysms, including vertebral artery ligations and vertebral artery bypasses (Table 2).

In other studies, there were no attempted direct repairs of the vertebral artery or C1-C2 fixations used to treat VAA dissections surgically. Overall, 30 VAAs were treated through vertebral artery sacrifice, while a vertebral artery preservation technique treated 48 VAAs. In our study, there was no difference between the complication rate regarding either vertebral artery treatment technique, as both consisted of a complication rate of 23% (Table 3). But VA sacrificial treatment techniques were associated with a higher mortality rate than the preservation techniques. Adjuvant antithrombotic therapy was used in 39% of cases though the type of anticoagulation therapy could not be determined or was not provided in 61% of the cases. The most common antiplatelet therapy utilized was a combination of either Clopidogrel, Aspirin, or both at varying doses.

Summary of findings

A total of 84 patients were included in our systematic review. Our results yielded 65 reports of extracranial VAAs, with dissecting (50%) as the most common morphology. The highest rate of complications and mortality following intervention was seen in patients who had undergone surgical repair and were treated with a vertebral artery sacrificial technique. Furthermore, extracranial vertebral artery pseudoaneurysms mostly have a successful occlusion rate (90.4%) regardless of intervention type.

General overview

Extracranial VAAs are often an asymptomatic condition. However, when symptomatic, they may become debilitating. Many extracranial VAAs or pseudoaneurysms are caused by penetrating or blunt trauma incidents. In addition, non-penetrating related etiologies may lead to vertebral artery complications such as atherosclerosis, syphilis, neurofibromatosis, rheumatoid arthritis, surgical complications, and vertebral fractures.⁷³ Clinical signs and symptoms may include dizziness, headaches, and neurologic deficits from cerebral ischemia or nerve compression.⁶⁷ These symptoms may progress and ultimately result in a rupture of the aneurysm, causing complications resulting in a reduced quality of life, suppressed functionality, or even death. To diagnose VAAs, computed tomographic angiography (CTA) is used to provide unique information about the size and configuration of the transverse foramina. More recently, contrast MR angiography with 3D FLASH sequence has been the method of choice for evaluating vertebral arteries.⁷²

Treatment/Outcomes

The management of extracranial VAAs or pseudoaneurysms is unique for each patient and, if asymptomatic, may consist of conservative therapies that may include anticoagulant medications or routine follow-up imaging.⁶⁰ Frequently, asymptomatic pseudoaneurysms are benign, and follow-up imaging can be sufficient. Symptomatic lesions, however, will usually require treatment.

Few studies reviewed the outcome of conservative management concerning symptomatic extracranial VAAs, mainly because persistent focal symptoms are often indicated as a reason for surgical or endovascular treatment intervention. The necessity of surgical or endovascular treatment for unruptured extracranial VAAs is controversial because an accurate estimate of the probability of rupture in the extracranial VAAs is not available.⁵³ But there are three situations when VAAs must be treated through intervention regardless of whether it is asymptomatic. Feinberg et al. explained how traumatic or dissecting aneurysms should not be treated conservatively due to the high chance of aneurysmal expansion followed by an infarction.²² A study by Ono et al. supported this through a series of 42 patients. Their analysis included 21 patients presenting with ruptured dissecting aneurysms (including 37 VA cases) and showed that surgical patients had significant advantages over those treated conservatively in rebleeding and mortality. Individuals with confirmed primary connective tissue disorders also require treatment regardless of the presence or absence of symptoms, as explained by Hiramatsu et al., describe how individuals with primary disorders, such as neurofibromatosis, must have their aneurysms repaired to decrease the high risk of AVF formation, fatal hemorrhage, and embolic stroke.²⁹ The third case in which conservative treatment should not be utilized for asymptomatic patients is if a complete spontaneous thrombosis is not expected without surgical intervention, which would prevent the patient from a rupture of their aneurysm at a later date.¹⁰

Overall, using conservative treatment to manage an extracranial VAA depends on each patient's clinical situation, such as the presence of primary pathological disorders, the probability of spontaneous thrombosis, and the morphology of the aneurysm. Alternative interventions utilizing surgery or endovascular approaches may occur, especially during symptomatic aneurysms/pseudoaneurysms, and depend on several factors, such as the disease's size, symptoms, morphology, and etiology. Chen et al. noted that surgical or endovascular proximal occlusion and external or internal trapping of dissecting aneurysms might increase the risk of ischemic complications resulting from occlusion of the VA, PICA, and perforating arteries, which have a significant impact on clinical outcomes.⁷⁴

Similarly, our analysis concluded that dissecting morphologies tend to have worse outcomes when compared with other aneurysm morphologies. However, further studies with larger comparable sample sizes are needed to validate these claims further. Selecting the appropriate approach is essential to ensure optimal outcomes for the patients. Stavrinou et al. noted that the endovascular approach was the most popular treatment utilizing either an occlusion or exclusion technique, including diverters.⁶⁰ This was further validated through the results in this systematic review, where an endovascular technique was utilized to treat 63% of the extracranial VAAs. The most recently developed endovascular technique for aneurysm treatment is the micropore flow-diverting stent, which induces aneurysm thrombosis and resolution through alteration of the aneurysm hemodynamics.⁴⁶

The most popular commercial flow diverter is the Pipeline Embolization Device (PED), which has been shown to have a six-month aneurysm obliteration rate of 82.9–87.5%, with a periprocedural complication rate of 6.3% and 1.5% mortality rate.^75,76 This is like the evidence in our data. PED was one of the most popular endovascular treatments and presented with a complete obliteration rate of 90%, a periprocedural complication rate, and a mortality rate of 0%. The PED has also been proven to be the most effective endovascular intervention involving the resolution of pseudoaneurysms. It does not require intra-aneurysmal manipulation, and adjuvant coiling is unnecessary, unlike graft stenting and coil embolization. ¹⁹

The intra-aneurysmal manipulation by other endovascular interventions may increase the chance for rebleeding and intraoperative rupture, and severe bleeding will be very high, especially in the acute setting of VA perforation by a screw.¹⁹ Furthermore, according to Kerolus et al., there is an advantage to utilizing PEDs compared to the conventional stent with coiling since PEDs can minimize the risk of persistent mass effect from coils while also causing occlusion of the pseudoaneurysm. ³⁷

Though endovascular treatments have proven to be popular and effective, including within the present study, where there was an overall complication rate of 7.8% and a mortality rate of 0%, it is important to note the need for surgical intervention is still essential in some cases.

Overall, a surgical intervention's mortality and morbidity rate were higher in our study than in endovascular interventions. However, the mortality and complication rates related to surgical intervention tended to have a diminishing trend as time progressed. The most recent studies reported relatively reduced mortality and morbidity compared to previous studies, which may suggest that more experience and better surgical tools are utilized for such procedures. It is also possible that patients with the surgical treatment had more severe initial presenting symptoms and thus were in a more critical condition than their counterparts, especially since it is standard to immediately perform a surgical intervention in hemodynamically unstable patients with suspected ruptured aneurysms.⁴

Ultimately, future clinical studies with larger sample sizes would have to be performed to validate whether surgical treatment predisposes patients to higher complications compared to endovascular interventions. Various studies and clinicians continue to stress the use of surgical techniques as still essential. This includes cases involving larger aneurysms and those located in the proximal extracranial vertebral artery segment.^56,77 Additionally, if a patient presents with hemodynamic instability and airway compromise resulting from an expanding hematoma, an open surgical approach is recommended.⁴ Although there have been various endovascular intervention advancements throughout the years, there is still no indication that endovascular treatment is the most advantageous in all situations.

How to Choose Optimal Treatment

When treating patients with an extracranial VAA, the optimal options will be best tailored for the individual patient. Different therapeutic methods can be chosen depending on the parent vessel's size, morphology, location, and desired patency. Studies have recommended that stable patients with pseudoaneurysms and arteriovenous fistulas should be managed with endovascular techniques and that arterial repair should be reserved for patients whose angiography demonstrates inadequate collateral circulation and for unstable patients with life-threatening hemorrhage.⁵⁵ Endovascular treatment is minimally invasive and has shorter operation durations, particularly for ruptured aneurysms. ⁵⁶

Stenting is usually prioritized, as it reconstructs the arterial lumen without compromising cerebral blood flow. Self-expanding stents are flexible, less traumatic, adapted better to arterial walls, and resistant to compression. In addition, stenting can induce spontaneous thrombosis and scaffold for coil embolization. However, its long-term safety and durability are relatively unknown, and the artery may occlude due to spasm, thrombosis, emboli, and restenosis. Furthermore, stents may cause dissection, rupture, or kinking of the parent artery during neck movements.

The size of the aneurysm may also determine what treatment should best be offered and avoided. Stravinou et al. explained how patients with wide-necked giant aneurysms represent a limitation of the coiling procedures due to the unacceptable risk of coil migration. The author suggested that combined treatment with coils and stents is the best procedure of choice in such cases.⁵⁷

VAA morphologies play a role in determining the best treatment option, such as dissecting aneurysms. Studies have suggested that patients with dissecting aneurysms are best treated with VA bypass instead of endovascular treatments.^60,65 Uneda et al. stated that the endovascular treatment of a ruptured aneurysm is minimally invasive. Of short surgical duration, if only the proximal parent artery is occluded, the aneurysm may persist, with recanalization by retrograde flow from the opposite vertebral artery.⁶⁵ Furthermore, Patel et al. mentioned that a parent vessel sacrifice yields good outcomes in individuals with dissecting aneurysms.⁴⁸ The location of the VAA may affect the best treatment option available. When treating a patient with a proximal VAA, it is best to treat by aneurysmectomy and vascular reconstruction whenever feasible. Infraoccipital revascularization procedures best treat patients with distal VAAs, most often a carotid-to-vertebral artery bypass with vein or transposition of the external carotid artery or by distal and proximal ligation of the vessel followed by resection of the lesion in the presence of a patent contralateral vertebral artery and normal posterior cerebral circulation.⁶² Though the best current role of the VA bypass is the treatment of distal VAAs, it is crucial to recognize that they can be technically demanding, present with significant procedure-related morbidity and mortality rates, graft occlusion occurred in 10% of patients, and symptomatic cure rate was about 60% in long term cases.⁷⁸ Utilizing a VA bypass can serve as a viable treatment option, primarily dependent on the surgeon's experience but may have various risks that must be considered. Primary surgical repair of vertebral artery aneurysms is notoriously difficult. It has been suggested to be considered in unstable patients with active hemorrhage and the rare cases when the contralateral vertebral artery is hypoplastic or absent.⁶⁰ The specific cervical level location may also be important in determining the best treatment option. Anderson et al. stated how a VAA at the C2 level would be best treated with an endovascular treatment instead of surgical. This is preferred due to the extensive work required for an open repair of the aneurysm, which requires a far lateral approach and extensive suboccipital dissection, as well as hemilaminectomy of C1 and C2 to obtain adequate vascular control proximally and distal to the aneurysm.¹¹ The extensive manipulation the surgical repair could expose the patient to is less advantageous than endovascular methods such as coiling. The desired patency of the parent vessel is also essential to consider for optimal treatment. Pataki et al. suggested that when preserving the patency of the parent artery is crucial, the use of stent grafts, flow diverters, or double-layer micromesh stents are the preferred endovascular treatment methods.⁴⁷ Ultimately, the optimal treatment method for patients with extracranial VAAs is determined by the characteristics of the individual's aneurysm.

There were several limitations to our study. First, most of the included studies were retrospective and had small sample sizes. Furthermore, most of the manuscripts consisted of case studies which may be prone to publication bias. Similarly, most of the reviewed series provided little information on long-term outcomes. Future studies should assess these factors and offer more studies to validate the analysis further.

In our systematic review of 84 patients across 65 studies, the rate of mortality following endovascular treatment of extracranial VAAs was found to be 0%, and after surgeries was 10.7%. Though most surgical complications and mortalities occurred earlier, the mortality rate among surgically treated individuals began to improve as time progressed. Individuals that underwent VA preservation treatment techniques had better mortality outcomes when compared to those who had VA sacrificial procedures. The most optimal treatment for patients with an extracranial VAA depends on the aneurysm's characteristics, such as location, size, morphology, and more. The impact of symptomatic extracranial VAAs can be profound, warranting further studies addressing successful interventions and post-treatment methods. The treatment of symptomatic extracranial VAAs is relatively safe and effective, especially when utilizing an endovascular treatment approach. Other studies are essential to understanding this rare disease.

Ethical Approval
N/A

Competing interests
N/A

Authors' contributions
Conceptualization: OA, ARB, AKG, Data Analysis: OA, ARB, AKG, WW. Manuscript Writing: OA, ARB, AKG, ABN, RJ. Editing: OA, AKG, ABN, RJ. Supervision: MB, BRB

Funding
N/A

Availability of data and materials
N/A

Merwick Á, Werring D. Posterior circulation ischaemic stroke. BMJ. 2014;348:g3175.
Cury M, Greenberg RK, Morales JP, Mohabbat W, Hernandez AV. Supra-aortic vessels aneurysms: diagnosis and prompt intervention. J Vasc Surg. 2009;49(1):4-10.
Gallot JC, Thomas P, Douvrin F, Clavier E, Watelet J, Plissonnier D. Treatment of Extracranial Vertebral Aneurysm Associated with Two Intracranial Aneurysms—A Case Report. EJVES Extra. 2005;10(6):142-145. doi:10.1016/j.ejvsextra.2005.08.010
Nenadic D, Balevic M, Milojevic M, Tanskovic S. Extracranial Vertebral Artery Aneurysm Rupture Complicated by Extrapleural Haematoma. EJVES Short Rep. 2018;38:12-14.
Website. Lampis C. Stavrinou, George Stranjalis, Pantelis C. Stavrinou, N. Bontozoglou, Damianos E. Sakas, “Extracranial Vertebral Artery Aneurysm Presenting as a Chronic Cervical Mass Lesion”, Case Reports in Medicine, vol. 2010, Article ID 938219, 3 pages, 2010. https://doi.org/10.1155/2010/938219
Choudhri O, Mukerji N, Steinberg GK. Combined endovascular and microsurgical management of complex cerebral aneurysms. Front Neurol. 2013;4:108.
Lehto H, Niemelä M, Kivisaari R, et al. Intracranial Vertebral Artery Aneurysms: Clinical Features and Outcome of 190 Patients. World Neurosurg. 2015;84(2):380-389.
Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1.
Ambekar S, Sharma M, Smith D, Cuellar H. Successful treatment of iatrogenic vertebral pseudoaneurysm using pipeline embolization device. Case Rep Vasc Med. 2014;2014:341748.
Anand VK, Raila FA, McAuley JR, Reed JM. Giant pseudoaneurysm of the extracranial vertical artery. Otolaryngol Head Neck Surg. 1993;109(6):1057-1060.
Anderson TCO, Ryo YWL, Fung MK, Man LW. MRI Vessel Wall Imaging and Treatment of an Aneurysm at the Atlanto-Axial Segment of an Aberrant Vertebral Artery. Neurointervention. 2018;13(1):62-65.
Antonov GI, Miklashevich ER, Gladyshev SY, Bogdanovich IO. New surgical treatment for vertebral artery pseudoaneurysm at the boundary between the V2 and V3 segments. Zh Vopr Neirokhir Im N N Burdenko. 2015;79(3):90-95.
Aoki H, Mizobe T, Nozuchi S, Hatanaka T, Tanaka Y. Vertebral artery pseudoaneurysm: a rare complication of internal jugular vein catheterization. Anesth Analg. 1992;75(2):296-298.
Badran K, Mani N, Axon P. Spontaneous parapharyngeal haematoma caused by a leaking vertebral artery pseudoaneurysm. European Archives of Oto-Rhino-Laryngology. 2008;265(2):251-254. doi:10.1007/s00405-007-0421-y
Bürger T, Meyer F, Halloul Z. Non-traumatic aneurysm of the extracranial vertebral artery. Eur J Surg. 2000;166(2):180-182.
Case ME, Archer CR, Hsieh V, Codd JE. Traumatic aneurysm of vertebral artery: a case report and review of the literature. Angiology. 1979;30(2):138-142.
Cohen JE, Gomori JM, Rajz G, et al. Vertebral artery pseudoaneurysms secondary to blunt trauma: Endovascular management by means of neurostents and flow diverters. J Clin Neurosci. 2016;32:77-82.
Detwiler K, Godersky JC, Gentry L. Pseudoaneurysm of the extracranial vertebral artery. Journal of Neurosurgery. 1987;67(6):935-939. doi:10.3171/jns.1987.67.6.0935
Dolati P, Eichberg DG, Thomas A, Ogilvy CS. Application of Pipeline Embolization Device for Iatrogenic Pseudoaneurysms of the Extracranial Vertebral Artery: A Case Report and Systematic Review of the Literature. Cureus. 2015;7(10):e356.
Evans K, Lindert RB, Dyde R, Tse GH. Chronic fusiform extracranial vertebral artery aneurysm with recurrent posterior circulation emboli: Case report and review of the literature. Interventional Neuroradiology. 2022;28(1):9-15. doi:10.1177/15910199211018581
Fandino J, Yonekawa Y, Wichmann WW, Roth P. Extradural vertebral artery dissecting aneurysm causing subarachnoid haemorrhage. Journal of Clinical Neuroscience. 1999;6(3):245-247. doi:10.1016/s0967-5868(99)90513-1
Feinberg RL, Sorrell K, Wheeler JR, et al. Successful management of traumatic false aneurysm of the extracranial vertebral artery by duplex-directed manual occlusion: A case report. Journal of Vascular Surgery. 1993;18(5):889-894. doi:10.1016/0741-5214(93)90346-n
Fuga M, Tanaka T, Tachi R, et al. Successful Endovascular Trapping for Symptomatic Thrombosed Giant Unruptured Aneurysms of the V1 and V2 Segments of the Vertebral Artery: Case Report and Literature Review. NMC Case Report Journal. 2021;8(1):681-690. doi:10.2176/nmccrj.cr.2021-0107
Gupta AK, Murumkar V, Peer S. Endovascular Management of Traumatic Vertebral Artery Pseudoaneurysm Associated with Vertebral Arteriovenous Fistula Using a Covered Stent. Cureus. Published online 2019. doi:10.7759/cureus.5716
Habozit B, Battistelli JM. Spontaneous Aneurysm of the Extracranial Vertebral Artery Associated with Spinal Osseous Anomaly. Annals of Vascular Surgery. 1990;4(6):600-603. doi:10.1016/s0890-5096(06)60847-9
Han KS, Lee KM, Kim BJ, Kwun BD, Choi SK, Lee SH. Life-Threatening Hemothorax Caused by Spontaneous Extracranial Vertebral Aneurysm Rupture in Neurofibromatosis Type 1. World Neurosurgery. 2019;130:157-159. doi:10.1016/j.wneu.2019.07.007
Hayes P, Gerlock AJ Jr, Cobb CA. Cervical spine trauma: a cause of vertebral artery injury. J Trauma. 1980;20(10):904-905.
Hiramatsu H, Negoro M, Hayakawa M, et al. Extracranial Vertebral Artery Aneurysm Associated with Neurofibromatosis Type 1. Interventional Neuroradiology. 2007;13(1_suppl):90-93. doi:10.1177/15910199070130s112
Hiramatsu H, Matsui S, Yamashita S, et al. Ruptured Extracranial Vertebral Artery Aneurysm Associated With Neurofibromatosis Type 1. Neurologia medico-chirurgica. 2012;52(6):446-449. doi:10.2176/nmc.52.446
Horowitz MB, Miller G 3rd, Meyer Y, Carstens G 3rd, Purdy PD. Use of intravascular stents in the treatment of internal carotid and extracranial vertebral artery pseudoaneurysms. AJNR Am J Neuroradiol. 1996;17(4):693-696.
Horsley M, Taylor TK, Sorby WA. Traction-Induced Rupture of an Extracranial Vertebral Artery Aneurysm Associated With Neurofibromatosis. Spine. 1997;22(2):225-227. doi:10.1097/00007632-199701150-00019
Ikeda N, Hayashi H, Goto M, Satoi H, Iwasaki K, Toda H. Posterior atlantoaxial fusion as treatment option for extracranial vertebral artery dissecting aneurysm: a case report and literature review. Acta Neurochirurgica. 2016;158(9):1741-1744. doi:10.1007/s00701-016-2891-4
Inaraja Pérez GC, Rodríguez Morata A, Reyes Ortega JP, Gómez Medialdea R, Cabezudo García P. Endovascular treatment of a symptomatic vertebral artery pseudoaneurysm. Ann Vasc Surg. 2015;29(5):1018.e5-e8.
Islamoğlu F, Posacioğlu H, Memiş A, Durmaz I. Endovascular transcatheter occlusion for traumatic vertebral artery pseudoaneurysm. Eur J Vasc Endovasc Surg. 2000;20(6):576-578.
Johnson-Mann C, Schonholz C, Vandergrift W, Elliott BM, Brothers T. Bypass and embolization for a vertebral artery aneurysm in a patient with Marfan syndrome. Journal of Vascular Surgery Cases. 2015;1(2):77-80. doi:10.1016/j.jvsc.2015.02.002
Kaplan SS, Ogilvy CS, Gonzalez R, Gress D, Pile-Spellman J. Extracranial vertebral artery pseudoaneurysm presenting as subarachnoid hemorrhage. Stroke. 1993;24(9):1397-1399.
Kerolus M, Tan LA, Chen M. Treatment of a giant vertebral artery pseudoaneurysm secondary to gunshot wound to the neck using pipeline embolization device. Br J Neurosurg. 2018;32(5):563-564.
Kollmann D, Kinstner C, Teleky K, et al. Successful Treatment of a Ruptured Extracranial Vertebral Artery Aneurysm with Onyx Instillation. Ann Vasc Surg. 2016;36:290.e7-e290.e10.
Kikuchi K, Kowada M. Nontraumatic extracranial aneurysm of the vertebral artery. Surgical Neurology. 1983;19(5):425-427. doi:10.1016/0090-3019(83)90139-8
Lee YJ, Ahn JY, Han IB, Chung YS, Hong CK, Joo JY. Therapeutic endovascular treatments for traumatic vertebral artery injuries. J Trauma. 2007;62(4):886-891.
Li F, Song X, Liu C, Liu B, Zheng Y. Endovascular Stent-Graft Treatment for a Traumatic Vertebrovertebral Arteriovenous Fistula with Pseudoaneurysm. Annals of Vascular Surgery. 2014;28(2):489.e11-e489.e14. doi:10.1016/j.avsg.2012.12.013
Morgan MK, Sekhon LH. Extracranial-intracranial saphenous vein bypass for carotid or vertebral artery dissections: a report of six cases. J Neurosurg. 1994;80(2):237-246.
Morasch MD, Phade SV, Naughton P, Garcia-Toca M, Escobar G, Berguer R. Primary extracranial vertebral artery aneurysms. Ann Vasc Surg. 2013;27(4):418-423.
Moriyama E, Kunishio K, Norikane H, Matsumoto Y, Shinohara C, Tokunaga K. Extracranial Vertebral Artery Aneurysm Causing Spinal Subarachnoid Hemorrhage —Case Report—. Neurologia medico-chirurgica. 1994;34(4):230-232. doi:10.2176/nmc.34.230
O’Connel JD, Sutton D, Kendall B. Traumatic vertebral artery aneurysm. Report of two cases. Br J Radiol. 1975;48(572):670-673.
Ouchi H, Ohara I, Iwabuchi T, Suzuki J. Dissecting aneurysm of the extracranial portion of the vertebral artery. Vasc Dis. 1965;2(6):340-344.
Pataki Á, Nguyen DT, Nagy Z, Nardai S, Nemes B. Stent-Graft Treatment of a Giant Asymptomatic Extracranial Vertebral Artery Aneurysm: Case Report and Literature Review. Annals of Vascular Surgery. 2022;79:442.e1-e442.e6. doi:10.1016/j.avsg.2021.08.023
Patel SM, Ojha S, Das S, Krishnan P. Extracranial Vertebral Artery Aneurysm: An Unpleasant Consequence of Neck Massage. Journal of Neurosciences in Rural Practice. 2018;09(04):655-657. doi:10.4103/jnrp.jnrp_118_18
Peyre M, Ozanne A, Bhangoo R, et al. PSEUDOTUMORAL PRESENTATION OF A CERVICAL EXTRACRANIAL VERTEBRAL ARTERY ANEURYSM IN NEUROFIBROMATOSIS TYPE 1. Neurosurgery. 2007;61(3):E658. doi:10.1227/01.neu.0000290919.47847.d7
Plou P, Landriel F, Beltrame S, et al. Flow Diverter for the Treatment of Pseudoaneurysms of the Extracraneal Vertebral Artery: Report of Two Cases and Review of the Literature. World Neurosurg. 2019;127:72-78.
Ronchey S, Serrao E, Kasemi H, Fazzini S, Mangialardi N. Endovascular treatment of extracranial vertebral artery aneurysm and aberrant right subclavian artery aneurysm. J Cardiovasc Surg . 2014;55(2):265-269.
Rosenblum B, Rifkinson-Mann S, Sacher M, Gennuso R, Rothman A. Hemodynamic analysis of associated extracranial atraumatic vertebral artery aneurysm and arteriovenous fistula. Journal of Neurosurgery. 1987;67(6):940-943. doi:10.3171/jns.1987.67.6.0940
Roper PR, Guinto FC Jr, Wolma FJ. Posttraumatic vertebral artery aneurysm and arteriovenous fistula: a case report. Surgery. 1984;96(3):556-559.
Royle CA, Craig RP, Reidy JF. Occlusion of a traumatic false aneurysm of the vertebral artery. Injury. 1986;17(1):57-58.
Sancak T, Bilgic S, Ustuner E. Endovascular stent-graft treatment of a traumatic vertebral artery pseudoaneurysm and vertebrojugular fistula. Korean J Radiol. 2008;9 Suppl(Suppl):S68-S72.
Schittek A. Pseudoaneurysm of the vertebral artery. Tex Heart Inst J. 1999;26(1):90-95.
Seifert T, Klein E, Legat-Wallner S, et al. Bilateral vertebral artery dissection and infratentorial stroke complicated by stress-induced cardiomyopathy. J Neurol Neurosurg Psychiatry. 2008;79(4):480-481.
Shakir HJ, Rooney PJ, Rangel-Castilla L, Yashar P, Levy EI. Treatment of iatrogenic V2 segment vertebral artery pseudoaneurysm using Pipeline flow-diverting stent. Surg Neurol Int. 2016;7:104.
Shang EK, Fairman RM, Foley PJ, Jackson BM. Endovascular treatment of a symptomatic extracranial vertebral artery aneurysm. J Vasc Surg. 2013;58(5):1391-1393.
Stavrinou LC, Stranjalis G, Stavrinou PC, Bontozoglou N, Sakas DE. Extracranial Vertebral Artery Aneurysm Presenting as a Chronic Cervical Mass Lesion. Case Reports in Medicine. 2010;2010:1-3. doi:10.1155/2010/938219
Strambo D, Peruzzotti-Jametti L, Semerano A, et al. Treatment Challenges of a Primary Vertebral Artery Aneurysm Causing Recurrent Ischemic Strokes. Case Reports in Neurological Medicine. 2017;2017:1-3. doi:10.1155/2017/2571630
Suliman AEA, Hamid HKS, Mekki SO. An unusual case of a giant extracranial vertebral artery aneurysm. Vascular. 2019;27(4):427-429. doi:10.1177/1708538119843403
Website.
Uekawa K, Kaku Y, Amadatsu T, et al. Intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis: A case report. Interv Neuroradiol. 2021;27(2):212-218.
Uneda A, Suzuki K, Okubo S, Hirashita K, Yunoki M, Yoshino K. Neurofibromatosis Type 1–Associated Extracranial Vertebral Artery Aneurysm Complicated by Vertebral Arteriovenous Fistula After Rupture: Case Report and Literature Review. World Neurosurgery. 2016;96:609.e13-e609.e18. doi:10.1016/j.wneu.2016.09.036
Ushikoshi S, Goto K, Uda K, Ogata N, Takeno Y. Vertebral arteriovenous fistula that developed in the same place as a previous ruptured aneurysm: a case report. Surgical Neurology. 1999;51(2):168-173. doi:10.1016/s0090-3019(98)00011-1
Wang Y, Jiao L. Endovascular Treatment of a Primary Extracranial Vertebral Artery Aneurysm Causing Ischemic Stroke. Neurol India. 2021;69(1):184-186.
Wiener I, Flye MW. Traumatic false aneurysm of the vertebral artery. J Trauma. 1984;24(4):346-349.
Wilkinson DL, Polak JF, Grassi CJ, Whittemore AD, O’Leary DH. Pseudoaneurysm of the vertebral artery: appearance on color-flow Doppler sonography. AJR Am J Roentgenol. 1988;151(5):1051-1052.
Wu H, Wang M, Li K, Wang F. Treatment of Extracranial Vertebral Artery Aneurysm with Flow Diversion. World Neurosurg. 2020;138:328-331.
Xu N, Zhang K, Meng H, Liu T, Wang H. Treatment of Spontaneous Dissecting Aneurysm in Extracranial Vertebral Artery with Covered Stent. World Neurosurg. 2018;110:e330-e332.
Yoon WK, Kim YW, Kim SD, Park IS, Baik MW, Kim SR. Intravascular ultrasonography-guided stent angioplasty of an extracranial vertebral artery dissection. J Neurosurg. 2008;109(6):1113-1118.
Sumimura J, Miyata M, Nakao K, Kamiike W, Yamaguchi T, Matsuda H. Primary malignant lymphoma of the spleen. Surgery Today. 1992;22(4):371-375. doi:10.1007/bf00308749
Chen YA, Qu RB, Bian YS, Zhu W, Zhang KP, Pang Q. Stent Placement to Treat Ruptured Vertebral Dissecting Aneurysms. Interventional Neuroradiology. 2013;19(4):479-482. doi:10.1177/159101991301900412
Leung GKK, Tsang ACO, Lui WM. Pipeline embolization device for intracranial aneurysm: a systematic review. Clin Neuroradiol. 2012;22(4):295-303.
de Barros Faria M, Castro RN, Lundquist J, et al. The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. AJNR Am J Neuroradiol. 2011;32(11):2192-2195.
Hatzitheofilou C, Demetriades D, Melissas J, Stewart M, Franklin J. Surgical approaches to vertebral artery injuries. British Journal of Surgery. 2005;75(3):234-237. doi:10.1002/bjs.1800750315
Kawabata Y, Tsukahara T, Fukuda S, Kawarazaki S, Aoki T. Successful endovascular treatment of a dissecting aneurysm of vertebral artery associated with double origin of the posterior inferior cerebellar artery. Interv Neuroradiol. 2016;22(1):62-66.

No competing interests reported.

Download PDF

Journal Publication

published 02 Oct, 2023

Read the published version in Neurosurgical Review →

Editorial decision: Major revision
13 Mar, 2023
Reviews received at journal
05 Mar, 2023
Reviewers agreed at journal
02 Mar, 2023
Reviewers agreed at journal
20 Feb, 2023
Reviewers agreed at journal
17 Feb, 2023
Reviewers invited by journal
13 Feb, 2023
Editor assigned by journal
13 Feb, 2023
Submission checks completed at journal
13 Feb, 2023
First submitted to journal
07 Feb, 2023

You are reading this latest preprint version

Outcomes Following Surgical and Endovascular Treatment of Extracranial Vertebral Artery Aneurysms (VAA): A Systematic Evaluation of the Literature

Status:

Journal Publication

Version 1

Abstract

Introduction:

Objective

Methods

Results

Conclusion

Figures

Introduction

Methods

Search Strategy

Selection Criteria

Data Extraction and Statistical Analysis

Results

Description of Studies

Treatment Interventions of Extracranial VAAs

Discussion

Summary of findings

General overview

Treatment/Outcomes

How to Choose Optimal Treatment

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1