Surgical and endovascular treatment of spinal dural arteriovenous fistulas: long-term disability assessment and prognostic factors

2001 ◽  
Vol 94 (2) ◽  
pp. 199-204 ◽  
Author(s):  
Joon K. Song ◽  
Fernando Viñuela ◽  
Y. Pierre Gobin ◽  
Gary R. Duckwiler ◽  
Yuichi Murayama ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Mr Imaging ◽  
Symptom Onset ◽  
Disability Score ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The authors assessed clinical outcomes of patients with treated spinal dural arteriovenous fistulas (DAVFs) and investigated prognostic factors. Methods. Thirty consecutive patients with spinal DAVFs were treated at the authors' institution during the past 15 years: seven underwent surgery; seven underwent surgery after failed embolization; and 16 underwent embolization alone. The outcomes of gait and micturition disability were analyzed. Follow up averaged 3.4 years (range 1 month–11.8 years). Age, duration of symptoms, pre- and postintervention magnetic resonance (MR) imaging findings, and preintervention disability were correlated with outcome. Seventeen patients (57%) experienced improved gait, 12 (40%) were unchanged, and one (3%) was worse. In 11 patients (37%) micturition function was improved, in 15 (50%) it was unchanged, and in four (13%) it was worse. Gait disability, as measured by the Aminoff—Logue Scale, was significantly improved after treatment, from 3.4 ± 1.4 (average ± standard deviation) to 2.7 ± 1.5 (p = 0.007). Mean micturition disability scores decreased, but not significantly, from 1.9 ± 1 to 1.6 ± 1.1 (p = 0.20). Preintervention gait disability was not associated with improvement except for patients with Aminoff—Logue Scale Grade 4 disability (eight of nine improved; p = 0.024). For patients treated within 13 months of symptom onset, mean micturition disability decreased (p = 0.035). No association was found between clinical improvement and age, a symptom duration less than 30 months, or pre- and postintervention MR imaging—documented spinal cord edema. Conclusions. Spinal DAVF treatment significantly improved patients' mean gait disability score by almost one grade at last follow up. The mean micturition disability score was not significantly improved, unless treatment was performed within 13 months of symptom onset. Longer and more uniform follow-up study is needed to determine if improved and stabilized clinical outcomes are sustained.

Embolization of spinal dural arteriovenous fistulas: importance of occlusion of the draining vein

2005 ◽  
Vol 2 (5) ◽  
pp. 580-583 ◽  
Author(s):  
Korné Jellema ◽  
Menno Sluzewski ◽  
Willem Jan van Rooij ◽  
Cees C. Tijssen ◽  
Guus N. Beute
Keyword(s):  
Treatment Option ◽  
Additional Treatment ◽  
The Other ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The aim of this study was to assess whether glue-induced occlusion of the draining vein predicts permanent closure of the fistula following embolization of spinal dural arteriovenous fistulas (SDAVFs). Methods. Between 1994 and 2004, 36 consecutive patients with an SDAVF were treated at the authors' institution. Twelve patients underwent surgery and 24 glue-based embolization. In 12 of 24 embolization procedures the draining vein was occluded and no recurrence or persistent fistula was seen during the follow-up period. In the other 12 patients the glue had not reached the draining vein and in eight of these the fistula recurred, necessitating additional treatment. Conclusions. In embolization of SDAVFs penetration of the glue into the draining vein predicts permanent closure of the fistula. When penetration of the glue into the draining vein can be expected, embolization is the preferred treatment option. In other cases surgery should be the treatment of choice.

Surgical interruption of intradural draining vein as curative treatment of spinal dural arteriovenous fistulas

1995 ◽  
Vol 82 (2) ◽  
pp. 196-200 ◽  
Author(s):  
John K. B. Afshar ◽  
John L. Doppman ◽  
Edward H. Oldfield
Keyword(s):  
Arterial Occlusion ◽  
Venous Drainage ◽  
Curative Treatment ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Flow Through ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

✓ To establish if interruption of the intradural draining spinal vein or surgical excision are curative treatments for spinal dural arteriovenous fistulas (AVFs), the medical records and radiographic studies of 19 patients with spinal dural AVFs and progressive myelopathy were reviewed. Spinal arteriograms were obtained before and within 2 weeks after surgery in 19 patients, and after a delay of 4 months or more in 11 patients. The mean clinical and arteriographic follow up was at 37 and 35 months, respectively. In the 11 patients who underwent excision of the dural AVF there was no evidence of a residual lesion upon immediate or delayed postoperative arteriography. Surgery in eight patients consisted of simple interruption of the intradural draining vein as it entered the subarachnoid space. In six of these patients the vein draining the AVF intrathecally provided the only venous drainage of the AVF. In these six patients there was no immediate (six of six) or delayed (four of six) arteriographic evidence of residual or recurrent flow through the AVF. Two patients had an AVF with both intra- and extradural venous drainage; after intradural division of the draining vein there was residual flow through the AVF into the extradural venous system. In one of these two patients intrathecal venous drainage was reestablished, which required additional therapy. In the other patient the extradural AVF spontaneously thrombosed and was not evident on delayed follow-up arteriography. In patients with spinal dural AVFs with only intrathecal medullary venous drainage, which includes most patients with these lesions, surgical interruption of the intradural draining vein provides lasting and curative treatment. In patients with both intra- and extradural drainage of the AVF, complete excision of the fistula or interruption of the intra- and extradural venous drainage of the fistula is indicated. In patients in whom a common vessel supplies the spinal cord and the dural AVF, simple surgical interruption of the vein draining the AVF is the treatment of choice, as it provides lasting obliteration of the fistula and it is the only treatment that does not risk arterial occlusion and cord infarction. Simple interruption of the venous drainage of a spinal dural AVF provides lasting occlusion of the fistula, as it does for cranial dural AVFs, if all pathways of venous drainage are interrupted. This result provides further evidence that the venous approach to the treatment of dural AVFs can be used successfully.

Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses

2001 ◽  
Vol 94 (6) ◽  
pp. 886-891 ◽  
Author(s):  
Jonathan A. Friedman ◽  
Bruce E. Pollock ◽  
Douglas A. Nichols ◽  
Deborah A. Gorman ◽  
Robert L. Foote ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Transarterial Embolization ◽  
Symptom Relief ◽  
Related Complication ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Lost To Follow Up ◽  
Fine Print

Object. Most dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses do not have angiographically demonstrated features associated with intracranial hemorrhage and, therefore, may be treated nonsurgically. The authors report their experience using a staged combination of radiosurgery and transarterial embolization for treating DAVFs involving the transverse and sigmoid sinuses. Methods. Between 1991 and 1998, 25 patients with DAVFs of the transverse and/or sigmoid sinuses were treated using stereotactic radiosurgery; 22 of these patients also underwent transarterial embolization. Two patients were lost to follow-up review. Clinical data, angiographic findings, and follow-up records for the remaining 23 patients were collected prospectively. The mean duration of clinical follow up after radiosurgery was 50 months (range 20–99 months). The 18 women and five men included in this series had a mean age of 57 years (range 33–79 years). Twenty-two (96%) of 23 patients presented with pulsatile tinnitus as the primary symptom; two patients had experienced an earlier intracerebral hemorrhage (ICH). Cognard classifications of the DAVFs included the following: I in 12 patients (52%), IIa in seven patients (30%), and III in four patients (17%). After treatment, symptoms resolved (20 patients) or improved significantly (two patients) in 96% of patients. One patient was clinically unchanged. No patient sustained an ICH or irradiation-related complication during the follow-up period. Seventeen patients underwent follow-up angiographic studies at a mean of 21 months after radiosurgery (range 11–38 months). Total or near-total obliteration (> 90%) was seen in 11 patients (65%), and more than a 50% reduction in six patients (35%). Two patients experienced recurrent tinnitus and underwent repeated radiosurgery and embolization at 21 and 38 months, respectively, after the first procedure. Conclusions. A staged combination of radiosurgery and transarterial embolization provides excellent symptom relief and a good angiographically verified cure rate for patients harboring low-risk DAVFs of the transverse and sigmoid sinuses. This combined approach is a safe and effective treatment strategy for patients without angiographically determined risk factors for hemorrhage and for elderly patients with significant comorbidities.

Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse—sigmoid sinus

2002 ◽  
Vol 96 (5) ◽  
pp. 823-829 ◽  
Author(s):  
David Hung-chi Pan ◽  
Wen-yuh Chung ◽  
Wan-yuo Guo ◽  
Hsiu-mei Wu ◽  
Kang-du Liu ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Neurological Complication ◽  
Endovascular Embolization ◽  
Sigmoid Sinus ◽  
Type I ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The aim of this study was to assess the efficacy and safety of radiosurgery for the treatment of dural arteriovenous fistulas (DAVFs) located in the region of the transverse—sigmoid sinus. Methods. A series of 20 patients with DAVFs located in the transverse—sigmoid sinus, who were treated with gamma knife surgery between June 1995 and June 2000, was evaluated. According to the Cognard classification, the DAVF was Type I in four patients, Type IIa in seven, Type IIb in two, and combined Type IIa+b in seven. Nine patients had previously been treated with surgery and/or embolization, whereas 11 patients underwent radiosurgery alone. Radiosurgery was performed using multiple-isocenter irradiation of the delineated DAVF nidus. The target volume ranged from 1.7 to 40.7 cm3. The margin dose delivered to the nidus ranged from 16.5 to 19 Gy at a 50 to 70% isodose level. Nineteen patients were available for follow-up review, the duration of which ranged from 6 to 58 months (median 19 months). Of the 19 patients, 14 (74%) were cured of their symptoms. At follow up, magnetic resonance imaging and/or angiography demonstrated complete obliteration of the DAVF in 11 patients (58%), subtotal obliteration (95% reduction of the nidus) in three (16%), and partial obliteration in another five (26%). There was no neurological complication related to the treatment. One patient experienced a recurrence of the DAVF 18 months after angiographic confirmation of total obliteration, and underwent a second course of radiosurgery. Conclusions. Stereotactic radiosurgery provides a safe and effective option for the treatment of DAVFs involving the transverse and sigmoid sinuses. For some aggressive DAVFs with extensive retrograde cortical venous drainage, however, a combination of endovascular embolization and surgery may be necessary.

Spinal dural arteriovenous fistulas: experience with endovascular and surgical therapy

2002 ◽  
Vol 96 (2) ◽  
pp. 162-167 ◽  
Author(s):  
Emad N. Eskandar ◽  
Lawrence F. Borges ◽  
Ronald F. Budzik ◽  
Christopher M. Putman ◽  
Christopher S. Ogilvy
Keyword(s):  
Surgical Therapy ◽  
Endovascular Therapy ◽  
Massachusetts General Hospital ◽  
Definitive Treatment ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Definitive Therapy ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

Object. Although the pathophysiology of spinal dural arteriovenous fistulas (AVFs) has recently been elucidated, the optimal treatment strategy for these lesions has yet to be defined. Current management techniques include endovascular embolization or microsurgical obliteration. Methods. The authors reviewed the records and angiograms of all patients with spinal dural AVFs treated at Massachusetts General Hospital over a 6-year period (1992–1998). During this period, it was intended initially to treat all patients with embolization and to reserve surgery for those in whom endovascular treatment failed or in cases in which pretreatment evaluation suggested that endovascular therapy would be ineffective or unsafe. A total of 26 patients with spinal dural AVFs were treated: there were 22 men and 4 women with a mean age of 65 years (range 39–79 years). Lesions were located in the following areas: five in foramen magnum/cervical, 13 in thoracic, five in lumbar, and three in sacral. Twenty-three (88%) of 26 patients underwent embolization and three (12%) of 23 patients underwent surgery as the primary mode of treatment. Of the 23 patients in whom embolization was performed or attempted, nine (39%) ultimately required surgery. All patients were stabilized or improved following definitive treatment, as assessed by the Aminoff—Logue scores. There was one death secondary to a myocardial infarction. Conclusions. These data demonstrate that endovascular therapy can be successful as an initial treatment for the majority of patients; however, there is a 39% failure rate, which is not observed following surgical therapy. Once a definitive therapy has been achieved using either technique virtually all patients are either stabilized or improved.

Benign cranial dural arteriovenous fistulas: outcome of conservative management based on the natural history of the lesion

2002 ◽  
Vol 97 (4) ◽  
pp. 767-770 ◽  
Author(s):  
Junichiro Satomi ◽  
J. MARC C. van Dijk ◽  
Karel G. Terbrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Conservative Management ◽  
Venous Drainage ◽  
Initial Assessment ◽  
Benign Condition ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Tolerable Level ◽  
Fine Print

Object. Cranial dural arteriovenous fistulas (DAVFs) can be classified into benign or aggressive, based on their patterns of venous drainage. A benign condition requires the absence of cortical venous drainage (CVD). The clinical and angiographic features of a consecutive single-center group of 117 patients harboring benign cranial DAVFs were evaluated over time to validate the behavior and appropriate management of these lesions. Methods. At the initial assessment four patients were asymptomatic. Two infants presented with congestive heart failure. All other patients presented with other benign symptoms: chronic headache, bruit, or orbital phenomena. Observational management was instituted in 73 patients (62%). Intolerable bruit or ophthalmological sequelae were deemed indications for palliative embolization in 43 patients and surgical treatment in one patient. A median follow-up period of 27.9 months (range 1 month—17.5 years) was available in 112 patients (95.7%), among whom repeated angiography was performed in 50. Overall, observational and palliative management resulted in a benign and tolerable level of disease in 110 (98.2%) of 112 cases. In two cases managed conservatively CVD developed. In both of these cases the conversion from benign to aggressive DAVF was associated with spontaneous progressive thrombosis of venous outlets. Conclusions. The disease course of a cranial DAVF without CVD is indeed benign, obviating the need for a cure of these lesions. Symptoms are well tolerated with either observation or palliative treatment. After a long-term follow-up review of 68 patients, this conservative management resulted in a benign and tolerable level of disease in 98.5% of cases. It is noteworthy, however, that a benign DAVF carries a 2% risk of developing CVD, mandating close clinical follow-up review in such cases and renewed radiological evaluation in response to any deterioration in the patient's condition.

Magnetic resonance imaging findings in treated spinal dural arteriovenous fistulas: lack of correlation with clinical outcomes

2011 ◽  
Vol 14 (4) ◽  
pp. 548-554 ◽  
Author(s):  
Timothy J. Kaufmann ◽  
Jonathan M. Morris ◽  
Andrea Saladino ◽  
Jay N. Mandrekar ◽  
Giuseppe Lanzino
Keyword(s):  
Spinal Cord ◽  
Mr Imaging ◽  
Clinical Outcomes ◽  
Imaging Findings ◽  
Urinary Function ◽  
Arteriovenous Fistulas ◽  
Imaging Characteristics ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas

Object Little information is available on follow-up MR imaging after treatment of spinal dural arteriovenous fistulas (DAVFs). The authors studied MR imaging findings in treated spinal DAVFs in relation to clinical outcomes. Methods A retrospective review of patients with spinal DAVFs who had undergone both pre- and postoperative spinal MR imaging was conducted. Postoperative MR images were obtained as routine follow-up studies or because of subjective or objective clinical deterioration. Several pre- and posttreatment MR imaging characteristics were evaluated by 2 neuroradiologists blinded to the clinical outcome. Clinical outcomes of motor, sensory, and urinary function (in relation to the patient's preoperative status) at the time of the postoperative MR imaging were obtained from the clinical record. The chi-square, Fisher exact, and rank-sum tests were performed to correlate imaging findings and changes with clinical outcomes. Results Thirty-four patients met inclusion criteria. Treatment was surgical in 33 patients and endovascular in 1 patient. Follow-up MR imaging was performed at a mean 168 ± 107 days after treatment. Twenty-seven patients (79.4%) were either clinically stable or improved, and 7 (20.6%) experienced worsening in one or more clinical outcomes. Most patients were found to have improvement of MR imaging changes. However, some degree of persistent spinal cord signal abnormality, enhancement, and swelling was observed in 31 (91.2%), 29 (85.3%), and 18 (52.3%) patients, respectively. Changes in these MR imaging characteristics compared with preoperative MR imaging did not correlate with clinical outcomes (p > 0.05), with the one exception of a significant correlation between change in urinary function and extent of spinal cord contrast enhancement (p = 0.026), a correlation of uncertain importance. Ten of the 34 patients underwent posttreatment digital subtraction angiography, and 3 of these patients had recurrent/residual DAVFs. Worsening of motor function significantly correlated with recurrent/residual DAVF (p = 0.053). Conclusions Spinal cord abnormalities persist on postoperative MR imaging studies in patients with treated spinal DAVFs, and although they tend to mildly improve with time, these changes may not correlate with clinical outcomes. However, regardless of imaging findings, worsening motor function may correlate with a recurrent or residual DAVF.

Selective disconnection of cortical venous reflux as treatment for cranial dural arteriovenous fistulas

2004 ◽  
Vol 101 (1) ◽  
pp. 31-35 ◽  
Author(s):  
J. Marc C. van Dijk ◽  
Karel G. TerBrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Dural Sinus ◽  
Venous Reflux ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Reflux ◽  
Sinus Drainage ◽  
Fine Print

Object. A single-institution series of 119 consecutive patients with a dural arteriovenous fistula (DAVF) and cortical venous reflux was reviewed to assess the overall clinical outcome of multidisciplinary management after long-term follow up. The selective disconnection of the cortical venous reflux compared with the obliteration of the entire DAVF was evaluated. Methods. Dural arteriovenous fistulas in patients in this series were diagnosed between 1984 and 2001, and treatment was instituted in 102 of them. The outcome of adequately treated patients was compared with that of a control group consisting of those with persistent cortical venous reflux and with data found in the literature. In cases of combined dural sinus drainage and cortical venous reflux, a novel treatment concept of selective disconnection of the cortical venous reflux that left the sinus drainage intact, and thus converted the aggressive DAVF into a benign lesion, was evaluated. Endovascular treatment, which was instituted initially in 78 patients, resulted in an obliteration or selective disconnection in 26 (25.5%) of 102 cases. In 70 cases (68.6%) the DAVFs were surgically obliterated or disconnected. In six cases (5.9%), patients were left with persistent cortical venous reflux. No lasting complications were noted in this series. Follow-up angiography confirmed a durable result in 94 (97.9%) of 96 adequately treated cases, at a mean follow up of 27.6 months (range 1.4–138.3 months). Selective disconnection was performed in 23 DAVFs with combined sinus drainage and cortical venous reflux. These patients' long-term outcomes were equal to those with obliterated DAVFs, and the complication rate was lower. Conclusions. Considering the ominous course of DAVFs with patent cortical venous reflux, multidisciplinary treatment of these lesions is highly effective and the complication rate is low. Selective disconnection provides a valid treatment option of DAVFs with combined dural sinus drainage and cortical venous reflux, as has been shown in cranial DAVFs with direct cortical venous reflux.

Gamma knife surgery for vestibular schwannoma: 10-year experience of 195 cases

2005 ◽  
Vol 102 (Special_Supplement) ◽  
pp. 87-97 ◽  
Author(s):  
Wen-Yuh Chung ◽  
Kang-Du Liu ◽  
Cheng-Ying Shiau ◽  
Hsiu-Mei Wu ◽  
Ling-Wei Wang ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Gamma Knife ◽  
Vestibular Schwannoma ◽  
Tumor Volume ◽  
Radiation Effect ◽  
Gamma Knife Surgery ◽  
Homogeneous Distribution ◽  
Content Type ◽  
Fine Print

Object. The authors conducted a study to determine the optimal radiation dose for vestibular schwannoma (VS) and to examine the histopathology in cases of treatment failure for better understanding of the effects of irradiation. Methods. A retrospective study was performed of 195 patients with VS; there were 113 female and 82 male patients whose mean age was 51 years (range 11–82 years). Seventy-two patients (37%) had undergone partial or total excision of their tumor prior to gamma knife surgery (GKS). The mean tumor volume was 4.1 cm3 (range 0.04–23.1 cm3). Multiisocenter dose planning placed a prescription dose of 11 to 18.2 Gy on the 50 to 94% isodose located at the tumor margin. Clinical and magnetic resonance (MR) imaging follow-up evaluations were performed every 6 months. A loss of central enhancement was demonstrated on MR imaging in 69.5% of the patients. At the latest MR imaging assessment decreased or stable tumor volume was demonstrated in 93.6% of the patients. During a median follow-up period of 31 months resection was avoided in 96.8% of cases. Uncontrolled tumor swelling was noted in five patients at 3.5, 17, 24, 33, and 62 months after GKS, respectively. Twelve of 20 patients retained serviceable hearing. Two patients experienced a temporary facial palsy. Two patients developed a new trigeminal neuralgia. There was no treatment-related death. Histopathological examination of specimens in three cases (one at 62 months after GKS) revealed a long-lasting radiation effect on vessels inside the tumor. Conclusions. Radiosurgery had a long-term radiation effect on VSs for up to 5 years. A margin 12-Gy dose with homogeneous distribution is effective in preventing tumor progression, while posing no serious threat to normal cranial nerve function.

A fatal, chronically growing basilar artery: a new type of dissecting aneurysm

1996 ◽  
Vol 84 (6) ◽  
pp. 962-971 ◽  
Author(s):  
Tohru Mizutani
Keyword(s):  
Mr Imaging ◽  
Basilar Artery ◽  
Dissecting Aneurysm ◽  
Neurological Deficits ◽  
Vertebrobasilar Insufficiency ◽  
Content Type ◽  
Asymptomatic Patients ◽  
Basilar Arteries ◽  
Fine Print

✓ A long-term follow-up study (minimum duration 2 years) was made of 13 patients with tortuous dilated basilar arteries. Of these, five patients had symptoms related to the presence of such arteries. Symptoms present at a very early stage included vertebrobasilar insufficiency in two patients, brainstem infarction in two patients, and left hemifacial spasm in one patient. Initial magnetic resonance (MR) imaging in serial slices of basilar arteries obtained from the five symptomatic patients showed an intimal flap or a subadventitial hematoma, both of which are characteristic of a dissecting aneurysm. In contrast, the basilar arteries in the eight asymptomatic patients did not show particular findings and they remained clinically and radiologically silent during the follow-up period. All of the lesions in the five symptomatic patients gradually grew to fantastic sizes, with progressive deterioration of the related clinical symptoms. Dilation of the basilar artery was consistent with hemorrhage into the “pseudolumen” within the laminated thrombus, which was confirmed by MR imaging studies. Of the five symptomatic patients studied, two died of fatal subarachnoid hemorrhage (SAH) and two of brainstem compression; the fifth patient remains alive without neurological deficits. In the three patients who underwent autopsy, a definite macroscopic double lumen was observed in both the proximal and distal ends of the aneurysms within the layer of the thickening intima. Microscopically, multiple mural dissections, fragmentation of internal elastic lamina (IEL), and degeneration of media were diffusely observed in the remarkably extended wall of the aneurysms. The substantial mechanism of pathogenesis and enlargement in the symptomatic, highly tortuous dilated artery might initially be macroscopic dissection within a thickening intima and subsequent repetitive hemorrhaging within a laminated thrombus in the pseudolumen combined with microscopic multiple mural dissections on the basis of a weakened IEL. The authors note and caution that symptomatic, tortuous dilated basilar arteries cannot be overlooked because they include a group of malignant arteries that may grow rapidly, resulting in a fatal course.

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