Anatomy-guided selection of reconstructive versus deconstructive endovascular strategies for intradural vertebral-artery dissecting aneurysms

BackgroundVertebral artery dissecting aneurysms (VADAs) pose therapeutic challenges when the posterior inferior cerebellar artery (PICA), anterior spinal artery (ASA), or dominant vertebral artery (VA) is involved.ObjectivesTo describe anatomical factors, treatment strategies, and clinical outcomes after endovascular therapy for VADAs.MethodsWe retrospectively reviewed prospectively collected data (January 2013-April 2025) on adults treated endovascularly for intradural VADAs. The primary outcome was 12-month modified Rankin Scale (mRS ≤ 2).ResultsNineteen patients (9 women, median age ≈52 years) were included. Most aneurysms were fusiform (12/19, 63.2%), and 8/19 (42.1%) presented ruptured. Flow diversion was the predominant treatment (12/19, 63.2%). At 12 months, 15/19 patients (78.9%) achieved a favorable mRS, while 4/19 (21.1%) were dependent or dead. Complications occurred in 4/19 (22.2%), most commonly ischemic events. Angiographic occlusion improved over time, with complete occlusion in 8/9 (88.9%) at 6 months and 3/5 (60.0%) at 12 months. Outcomes were favorable across anatomical subgroups, with no consistent differences by PICA or ASA involvement or VA dominance.ConclusionsOptimal VADA management relies on anatomy: parent-artery occlusion suits nondominant VAs with contralateral and PICA collaterals, while branch-preserving flow diversion (often with adjunctive coils at the PICA origin) is preferred for dominant-side or PICA/ASA-related dissections.