Advertisement

Vertebral Artery Aneurysm: Severe Subarachnoid Hemorrhage, Dissecting Pseudoaneurysm of the Vertebral Artery, and Reconstructive Treatment Using Telescoping Pipeline Flow Diverters

  • Franziska Dorn
Living reference work entry

Later version available View entry history

Abstract

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.

Keywords

Dissecting aneurysm Vertebral artery Pseudoaneurysm SAH Flow diverter Telescoping 

References

  1. Cerejo R, Bain M, Moore N, Hardman J, Bauer A, Hussain MS, Masaryk T, Rasmussen P, Flow TG. Diverter treatment of intracranial vertebral artery dissecting pseudoaneurysms. J Neurointerv Surg. 2017;9(11):1064–8.  https://doi.org/10.1136/neurintsurg-2017-013020.CrossRefPubMedGoogle Scholar
  2. Ducruet AF, Crowley RW, Albuquerque FC, McDougall CG. Reconstructive endovascular treatment of a ruptured vertebral artery dissecting aneurysm using the pipeline embolization device. J Neurointerv Surg. 2013;5(4):e20.  https://doi.org/10.1136/neurintsurg-2012-010358.CrossRefPubMedGoogle Scholar
  3. Fang YB, Wen WL, Yang PF, Zhou Y, Wu YN, Hong B, Xu Y, Zhao WY, Liu JM, Huang QH. Long-term outcome of Tubridge flow diverter(s) in treating large vertebral artery dissecting aneurysms-a pilot study. Clin Neuroradiol. 2017;27(3):345–50.  https://doi.org/10.1007/s00062-015-0494-8.CrossRefPubMedGoogle Scholar
  4. Kabbasch C, Mpotsaris A, Behme D, Dorn F, Stavrinou P, Liebig T. Pipeline Embolization LT. Device for treatment of intracranial aneurysms – the more, the better? A single-center retrospective observational study. J Vasc Interv Neurol. 2016;9(2):14–20.Google Scholar
  5. Kashiwazaki D, Ushikoshi S, Asano T, Kuroda S, Long-term HK. Clinical and radiological results of endovascular internal trapping in vertebral artery dissection. Neuroradiology. 2013;55(2):201–6.  https://doi.org/10.1007/s00234-012-1114-9.CrossRefPubMedGoogle Scholar
  6. Kim BM, Shin YS, Kim SH, Suh SH, Ihn YK, Kim DI, Kim DJ, Park SI. Incidence and risk factors of recurrence after endovascular treatment of intracranial vertebrobasilar dissecting aneurysms. Stroke. 2011;42(9):2425–30.  https://doi.org/10.1161/STROKEAHA.111.617381.CrossRefPubMedGoogle Scholar
  7. Madaelil TP, Wallace AN, Chatterjee AN, Zipfel GJ, Dacey RG Jr, Cross DT 3rd, Moran CJ, Derdeyn CP. Endovascular parent vessel sacrifice in ruptured dissecting vertebral and posterior inferior cerebellar artery aneurysms: clinical outcomes and review of the literature. J Neurointerv Surg. 2016;8(8):796–801.  https://doi.org/10.1136/neurintsurg-2015-011732.CrossRefPubMedGoogle Scholar
  8. Matouk CC, Kaderali Z, terBrugge KG, Willinsky RA. Long-term clinical and imaging follow-up of complex intracranial aneurysms treated by endovascular parent vessel occlusion. AJNR Am J Neuroradiol. 2012;33(10):1991–7.  https://doi.org/10.3174/ajnr.A3079.CrossRefPubMedGoogle Scholar
  9. Mazur MD, Kilburg C, Wang V, Pipeline TP. Embolization device for the treatment of vertebral artery aneurysms: the fate of covered branch vessels. J Neurointerv Surg. 2016;8(10):1041–7.  https://doi.org/10.1136/neurintsurg-2015-012040.CrossRefPubMedGoogle Scholar
  10. Mizutani T, Aruga T, Kirino T, Miki Y, Saito I, Recurrent TT. Subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery. 1995;36:905–11.CrossRefPubMedGoogle Scholar
  11. Rabinov JD, Hellinger FR, Morris PP, Ogilvy CS, Putman CM. Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol. 2003;24(7):1421–8.PubMedGoogle Scholar
  12. Santos-Franco JA, Zenteno M, Lee A. Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options. Neurosurg Rev. 2008;31(2):131–40.; ; discussion 140.  https://doi.org/10.1007/s10143-008-0124-x.CrossRefPubMedGoogle Scholar
  13. Sönmez Ö, Brinjikji W, Murad MH, Lanzino G. Deconstructive and reconstructive techniques in treatment of vertebrobasilar dissecting aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2015;36(7):1293–8.  https://doi.org/10.3174/ajnr.A4360.CrossRefPubMedGoogle Scholar
  14. Zhao KJ, Fang YB, Huang QH, Xu Y, Hong B, Li Q, Liu JM, Zhao WY, Deng BQ. Reconstructive treatment of ruptured intracranial spontaneous vertebral artery dissection aneurysms: long-term results and predictors of unfavorable outcomes. PLoS One. 2013;8(6):e67169.  https://doi.org/10.1371/journal.pone.0067169.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Department of NeuroradiologyUniversity Hospital of Munich, Campus GrosshadernMunichGermany

Personalised recommendations