title: Intracranial vertebral artery dissection with subarachnoid hemorrhage: clinical characteristics and outcomes in conservatively treated patients.
abstract: OBJECTIVE
  Intracranial vertebral artery (VA) dissection with subarachnoid hemorrhage is notorious for frequent rebleeding and a poor prognosis. Nevertheless, some patients survive with a good final outcome. The factors associated with the prognosis of this disease are not fully understood and appropriate treatment strategies continue to be debated. The authors retrospectively evaluated the clinical features of conservatively treated patients to elucidate the relationship between the clinical and angiographic characteristics of the disease and final outcomes.
  
  
  METHODS
  This study includes 24 patients who were treated by conservative methods between 1990 and 2000. Conservative treatment was chosen because of delayed diagnosis, poor clinical condition, or anatomical features such as bilateral lesions and contralateral VA hypoplasia. Of nine patients with an admission Hunt and Kosnik Grade I or II, eight had good outcomes (mean follow-up period 8 years and 4 months). All 15 patients with Grade III, IV, or V died and in 10 of these the cause of death was rebleeding. Among the 24 patients, 14 suffered a total of 35 rebleeding episodes; in 10 (71.4%) of these 14 patients rebleeding occurred within 6 hours and in 13 (93%) within 24 hours. Compared with the survivors, there was a female preponderance (0.022) among patients who died. These patients also had significantly shorter intervals between onset and hospital admission (p = 0.0067), a higher admission Hunt and Kosnik grade (p = 0.0001), a higher incidence of prehospitalization (p = 0.0296) and postadmission (p = 0.0029) rebleeding episodes, and a higher incidence of angiographically confirmed pearl-and-string structure of the lesion (p = 0.0049).
  
  
  CONCLUSIONS
  In our series of preselected patients, poor admission neurological grade, rebleeding episode(s), and lesions with a pearl-and-string structure were predictive of poor outcomes. Our findings indicate that patients with these characteristics may be candidates for aggressive attempts to prevent rebleeding during the acute stage. Patients without these characteristics may be good candidates for conservative treatment, especially those who survive the acute phase without rebleeding.
authors.affiliation: Department of Neurosurgery, Kitasato University School of Medicine, Kanagawa, Japan. yamadam@med.kitasato-u.ac.jp
authors.forename: Masaru
authors.initials: M
authors.lastname: Yamada
authors.forename: Takao
authors.initials: T
authors.lastname: Kitahara
authors.forename: Akira
authors.initials: A
authors.lastname: Kurata
authors.forename: Kiyotaka
authors.initials: K
authors.lastname: Fujii
authors.forename: Yoshio
authors.initials: Y
authors.lastname: Miyasaka
mesh_terms: D000210:Acute-Phase Reaction / Q000209:etiology* / Q000628:therapy*; D000328:Adult; D000368:Aged; D002533:Cerebral Angiography; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012008:Recurrence; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D020217:Vertebral Artery Dissection / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy*