American Journal of Medical Case Reports, 2017, Vol. 5, No. 8, 202-204 Available online at http://pubs.sciepub.com/ajmcr/5/8/2 ©Science and Education Publishing DOI:10.12691/ajmcr-5-8-2 Unruptured Vertebral Artery Dissecting Aneurysms: Approach Strategy by Retrospective Analysis Arash Dooghaie Moghadam 1 , Ali Keipourfard 2 , Yasaman Arjmand 1,* 1 Department of Radiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Bone Joint and Related Tissue Research Center, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran *Corresponding author: yasi.arj@gmail.com Abstract Objectives: The natural course of un-ruptured vertebral artery dissecting aneurysms (VADAs) is not completely clear. We aim to retrospectively develop a strategy for treating un-ruptured VADAs based on long-term follow-up. Methods: We retrospectively studied 35 patients with un-ruptured VADAs. The initial symptom of 20 patients was headache, followed by ischemic symptoms and mass effect in 11 and 4 patients respectively. All of the patients underwent Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) at the time of admission and 2 weeks and 1, 4, 6, 12, and 24 months after initial presentation. Asymptomatic patients with enlarging dissection site defined on MRI and MRA, received further treatment and work up. Results: Two patients received emergency intervention due to symptom exacerbation and unstable status. The other 33 patients underwent conservative management. Lesion enlargement was observed in 2 cases during imaging follow up. In follow up period, additional interventions including dissection trap by surgery and coil embolization were conducted in 1 and 3 patients respectively. Other 31 patients remain symptom free and were managed conservatively. Dissection site remained unchanged in majority of patients (68.57%), improved in 28.57% and disappeared in 2.85% of the patients. Ten patients with recurrent ischemic attacks underwent anti-platelet therapy, without any bleeding complaint or permanent neurological deficits. Conclusion: The nature of an un-ruptured VADA is not highly aggressive. However, enlarged dissection site without new manifestations, occlusion is recommended. Also, anti-platelet therapy is suggested in patients with recurrent ischemic attacks. Keywords: vertebral artery dissecting aneurysm, magnetic resonance imaging, conservative treatment, recurrent ischemic attacks, anti-platelet therapy Cite This Article: Arash Dooghaie Moghadam, Ali Keipourfard, and Yasaman Arjmand, “Unruptured Vertebral Artery Dissecting Aneurysms: Approach Strategy by Retrospective Analysis.” American Journal of Medical Case Reports, vol. 5, no. 8 (2017): 202-204. doi: 10.12691/ajmcr-5-8-2. 1. Introduction Dissection of an un-ruptured intracranial vertebral artery aneurysm (VAA) is one of the most identifiable causes of stroke in young adults and will manifest either as severe headache in occipital lobe or focal neurological deficits (transient or permanent) caused by vertebro-basilar artery ischemia. [1,2,3] These lesions tend to occur equally in men and women in their 40s and also are more common in patients with connective tissue disorders. [4] Subarachnoid hemorrhage (SAH) is the primary manifestation in patients with ruptured VAAs. The natural course of VAA strongly depends on primary manifestation. Due to high mortality rate of acute phase re-bleeding, open surgery or endovascular procedures are commonly performed in patients presenting with SAH or unstable status. [5] Satisfactory prognosis and non-aggressive nature of un-ruptured VAAs, advocates conservative management of these lesions. [6] Since there is no unified and acceptable follow-up and treatment have not been defined, we plan to investigate the natural history and of un-ruptured vertebral artery dissecting aneurysms (VADAs). 2. Methods Between October 2011 and March 2016, 20 male and 15 female patients (N=35) with un-ruptured VADAs with signed informed patient consent form were admitted to Shohada Tajrish Hospital. Stable patients with isolated headache were treated conservatively, while patients with progressive ischemic and mass effect symptoms received anti-platelet and steroid therapy respectively. Angiography was performed in patients who fail to improve despite mentioned appropriate treatments. Patient’s systolic blood pressure was maintained at 140 mmHg or bellow. All of the patients were studied by MRI and MRA, by focusing on series of diagnostic criteria, such as stenotic segments as string sign, occluded segments, pseudo-aneurysm and irregularity of lumen. MRI and MRA were performed at the end of the second week, followed by 1 st , 4 th , 6 th , 12 th and 24 th months later. Asymptomatic patients with enlarging dissection site on MRI and MRA and patients with progressive focal neurological symptoms despite anti-platelet therapy underwent angiography, by a 6- French guiding catheter and a non-detachable balloon as a