Flow diversion versus conventional endovascular treatment for ruptured basilar artery dissecting aneurysms: a single-center cohort study.

Background: Ruptured basilar artery dissecting aneurysms (BADAs) are rare and associated with high risks of rebleeding, brainstem ischemia, and death. Evidence specific to the basilar artery remains limited, and experience derived from vertebral artery dissections may not be directly transferable because the basilar trunk supplies numerous critical pontine perforators and generally cannot be sacrificed. Objective: To describe the real-world management of a consecutive cohort of ruptured BADA and compare long-term clinical outcomes after primary flow diverter (FD)-based versus conventional endovascular treatment. Methods: This retrospective single-center cohort study included consecutive patients with angiographically confirmed ruptured BADA who underwent endovascular treatment between February 2015 and April 2024. Patients were classified according to the index endovascular treatment as the FD group or the conventional endovascular treatment group. The primary outcome was favorable functional outcome (mRS 0-2) at the last follow-up. Secondary outcomes included mortality, retreatment, complications, and descriptive radiological outcomes. Results: Twenty-two patients were included: 5 received FD-based treatment as the index strategy and 17 received conventional endovascular treatment. Fusiform morphology was more frequent in the FD group (80.0% vs. 23.5%, Conclusion: Primary FD-based reconstruction was feasible in selected ruptured BADA, particularly in anatomically complex or fusiform lesions. Given the small sample, non-randomized treatment selection, and absence of statistically significant between-group differences, these findings support individualized treatment and do not establish superiority of either strategy.