Vertebral Artery Aneurysm: Severe Subarachnoid Hemorrhage, Dissecting Pseudoaneurysm of the Vertebral Artery, and Reconstructive Treatment Using Telescoping Pipeline Flow Diverters
A dissection of the V4 segment of the left vertebral artery (VA) was treated with telescoping flow diverters. The patient presented with severe subarachnoid hemorrhage (SAH), Fisher grade IV, three days after he had undergone tumor nephrectomy at an external hospital. After the surgery, he complained about neck pain before he progressively developed a right-sided hemiparesis and finally lost consciousness. An external ventricle drainage was applied after intubation, and the patient was transferred to our center. DSA confirmed a dissection of the left intradural vertebral artery (V4), including the origin of the posterior inferior cerebellar artery (PICA), and reconstructive treatment with a total of three telescoping Pipeline Embolization Devices (PED, Medtronic) was performed under antiplatelet medication with tirofiban. Follow-up DSA examinations seven and 11 days after the treatment revealed progressive yet incomplete occlusion of the false vessel lumen. Finally, the follow-up DSA after five months demonstrated the complete reconstruction of the previously dissected artery with patency of the PICA. No procedure-related ischemic events occurred. Ruptured vertebrobasilar dissecting aneurysms are associated with a poor natural history with high rates of re-rupture, stroke, and death when left untreated. For decades, parent vessel occlusion has been the treatment of choice. It is technically straightforward and has the advantage of an immediate occlusion of the pseudoaneurysm, and there is usually no need for antiplatelet medication; however, more sophisticated treatment options, such as bypass surgery or reconstructive endovascular treatment with flow diverters, must be discussed if the origin of the PICA and/or the anterior spinal artery is involved or in patients with a dissection of a dominant vertebral artery or in an isolated vertebrobasilar circulation.
KeywordsDissecting aneurysm Vertebral artery Pseudoaneurysm SAH Flow diverter Telescoping
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