Endovascular reconstruction of vertebral artery dissecting aneurysms with covered stents: A case series and embryology-based framework for safe segmental deployment

Title : Endovascular reconstruction of vertebral artery dissecting aneurysms with covered stents: A case series and embryology-based framework for safe segmental deployment

Abstract:

Background: Vertebral artery dissecting aneurysms (VADA) are an uncommon but life-threatening cause of subarachnoid hemorrhage and posterior-circulation stroke. Covered stents are an effective, economical option where flow-diverter availability is limited, but unlike porous flow-diverters they irreversibly exclude every branch arising under the graft. Safe deployment therefore depends on the segmental perforator anatomy of the vertebrobasilar system, which is dictated by its embryology. We present four cases and propose an embryology-grounded framework for safe segmental deployment.
Methods: We retrospectively reviewed four patients with VADA treated by covered-stent reconstruction. Pre-procedural cone-beam CT (CBCT) mapped brainstem perforators, the PICA origin, and the anterior spinal artery (ASA) origin relative to the dissecting segment. Immediate and 6-month angiographic and clinical outcomes were recorded, and the embryological and coil-occlusion literature was synthesized into a segmental decision framework.
Results: Four patients (a 52-year-old woman, a 48-year-old man, a 29-year-old man, and a 48-year-old woman) with fusiform V4 dissecting aneurysms underwent covered-stent reconstruction via radial access; in one case a Promus drug-eluting stent was telescoped within the covered stent to optimize apposition. Presentations ranged from WFNS Grade II subarachnoid hemorrhage to ischemic stroke. Immediate angiography showed complete exclusion with preserved parent-vessel patency in all four; at 6 months, all had a modified Rankin Scale score of 0 with stable angiographic exclusion. Embryologically, the V4 uniquely bridges the segmental vertebral artery and the non-segmental basilar system, concentrating non-redundant perforators—including the ASA rami—within a short course. Three operationally distinct V4 zones emerge: sub-PICA (favorable), PICA-involving (contraindicated), and supra-PICA (safe only with a bilateral or contralateral ASA origin).
Conclusion: Covered stents achieved durable VADA exclusion with mRS 0 in all patients when guided by CBCT mapping. Lesion location relative to the PICA, ASA-origin laterality, and perforator-free window length should jointly guide device selection.

Keywords: vertebral artery dissecting aneurysm; covered stent; anterior spinal artery; embryology; cone-beam CT.

Biography:

Venkata Sai Sulekhya Inturu is an international medical graduate (IMG) from India and a graduate of Mamata Medical College, with a path into neurology that runs from the wet lab to the angiography suite and from sequencing Alzheimer's mutations at NIMHANS to studying carotid stent fractures and vascular access-site strategies in interventional neurology. Hands-on electives in stroke and EEG sharpened my clinical eye, while co-authored work in the Journal of Neuroscience Research and Neurology grounds my research. Beyond the clinic, she have remained committed to service through volunteer and student organizations. She is a student member of the American Academy of Neurology and a former Vice President of the Walter E. Dandy Neurological Society, India.