Rebleeding of a vertebral artery dissecting aneurysm during stent-assisted coil embolization: a pitfall of the "stent and coil" technique

BACKGROUND: A stent-assisted coil embolization has been applied as a novel choice of treatment for vertebral artery dissecting aneurysms (VADAs). CLINICAL PRESENTATION: A 45-year-old man suffered from subarachnoid hemorrhage three times within 2 hours. The left vertebral angiogram showed a VADA at the distal origin of the posterior inferior cerebellar artery. The right vertebral artery was hypoplastic, and collateral circulation to the posterior fossa was poor. INTERVENTION: Stent-assisted coil embolization was performed under general anesthesia. The aneurysm was excluded from the circulation with good patency of the vertebral artery, although the fourth coil caused rebleeding from the aneurysmal dome during the procedure. CONCLUSION: This is the first case report that demonstrates rebleeding from VADA during stent-assisted coil embolization in the acute stage of its rupture. We have to be aware of the risks and be ready to prevent fatal complications with this novel technique.     

Postoperative hemorrhage due to normal pressure hyperperfusion breakthrough after a trapping of VA-PICA dissecting aneurysm

We described a case of cerebellar hemorrhage after trapping of a vertebral artery dissecting aneurysm. A forty-eight-year-old man had suffered from severe headache, vomiting and disturbance of consciousness. He was transferred to our hospital in an ambulance. Emergency CT scan showed subarachnoid hemorrhage in the posterior fossa predominantly, intraventricular hemorrhage and hydrocephalus change. Chest X-ray showed radiological evidence of pulmonary edema. The initial blood-gas determinations demonstrated a marked reduction in PaO2 and increased PaCO2. Five days after admission, the patient's condition was improving. Cerebral angiography was performed using the Seldinger method. It revealed a right vertebral artery dissecting aneurysm just distal to the posterior inferior cerebellar artery. We performed an operation to trap the VA dissecting aneurysm. Blood pressure was well controlled under 140 mmHg during the operation and he recovered from anesthesia completely. On the day after the operation, suddenly the patient's consciousness began to deteriorate. Emergency CT scan was performed and it showed SAH, cerebellar hemorrhage and diffuse swelling of the cerebellum on the same side as the operation. We suspected rebleeding of the aneurysm due to a clip's having slipped. Reoperation was performed, but the clip was not displaced and there were no definite bleeding vessels on the operative field. Consequently only external decompression and resection of the right cerebellum were performed. We discuss pathogenesis of the occurrence of hemorrhage in this particular case after trapping. We also review the relevant literature.     

Familial cerebral aneurysms in three families, with two sibling pairs

The authors describe two pairs of siblings and a mother-son with cerebral aneurysms and the characteristics of familial intracranial aneurysms are briefly discussed. Family 1: A 54-year-old hypertensive woman (case 1) developed subarachnoid hemorrhage and a saccular aneurysm at the proximal portion of the left anterior cerebral artery was demonstrated on the angiogram. An azygos anterior cerebral artery was found as an associated anomaly. A 53-year-old hypertensive woman (case 2), a younger sister of case 1, suffered from subarachnoid hemorrhage and a saccular aneurysm at the distal portion of the right anterior cerebral artery was found on the angiogram. Vertebral angiogram showed bilateral fenestration of the extracranial vertebral arteries as a coincidental anomalies. Neck clipping for the aneurysms were successfully done in these two cases. Family 2: A 52-year-old hypertensive woman (case 3) suffered from subarachnoid hemorrhage and vertebral angiogram demonstrated a saccular aneurysm at the distal portion of the right posterior inferior cerebellar artery. The aneurysm was re-bled before surgical intervention and she died five days after admission. A 65-year-old hypertensive woman (case 4), an elder sister of case 3, was admitted with subarachnoid hemorrhage. Vertebral angiogram showed a saccular aneurysm on the proximal portion of the left posterior inferior cerebellar artery at the junction of the vertebral artery and a massive extravasation of the contrast medium from the aneurysm. The patient died three days after the onset before surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Internal trapping of a ruptured vertebral artery dissecting aneurysm followed by recanalization of the trapped vertebral artery without aneurysm recurrence: case report

A 61-year-old man presented with a ruptured vertebral artery dissecting aneurysm manifesting as severe headache, which was treated by internal trapping, and later resulted in recanalization of the affected vertebral artery without aneurysm recurrence. Computed tomography revealed subarachnoid hemorrhage caused by a dissecting right vertebral artery aneurysm located just distal to the origin of the posterior inferior cerebellar artery. The patient underwent uneventful internal trapping. However, recanalization of the affected vertebral artery with stenosis was found on the 22nd postoperative day, apparently caused by insufficient thrombosis related to the short trapping length. No aneurysm recurrence or ischemic events were detected, so the patient was observed carefully. After 4 months, right vertebral angiography revealed that the vertebral artery was normal with no stenosis or aneurysm. Restoration of the vertebral artery without complication probably occurred by complete thrombosis of the aneurysm followed by reconstruction of the injured arterial wall. We adopted a conservative approach in this case, but additional embolization and/or stenting should be considered if high risk of rebleeding is suggested by angiographic findings, although the management of recanalization remains controversial.     

Dissecting aneurysm of the posterior inferior cerebellar artery; a case report]

A case of a dissecting aneurysm of the left posterior inferior cerebellar artery caused by giant cell angiitis is presented. A 22-year-old woman was admitted on August 30, 1990, with sudden onset of severe occipital headache and vomiting. Neurological examination on admission only showed severe meningismus. CT scan demonstrated subarachnoid hemorrhage and a small hematoma in the 4th ventricle. A left vertebral angiogram demonstrated that the left posterior inferior cerebellar artery was occluded at the lateral medullary segment. We diagnosed subarachnoid hemorrhage from a dissecting aneurysm. On the day following admission, the patient underwent a left suboccipital craniectomy. The posterior inferior cerebellar artery was enlarged for a distance of about 8 mm and there was typical purplish-red appearance in the dissecting aneurysm. This aneurysm was excised after trapping. The histological diagnosis was primary localized giant cell angiitis without systemic involvement. The etiology of the intracranial dissecting aneurysm is obscure, but this report suggests that cerebral angiitis can be considered as an important factor.     

Dissecting vertebral aneurysm with subarachnoid hemorrhage after ischemic onset on the same day: a case report

We report a case of a dissecting vertebral aneurysm with subarachnoid hemorrhage (SAH) after ischemic onset on the same day. A 48-year-old man had abrupt vertigo and nausea. CT & MRI on admission showed no abnormality, but he complained of left hemiparesis after admission. Twelve hours after the ischemic onset he suddenly complained of severe headache and his consciousness deteriorated. The follow-up CT showed diffuse SAH. Cerebral angiography showed occlusion of the right vertebral artery at the origin of the posterior inferior cerebellar artery (PICA) and segmental stenosis of the left vertebral artery at the portion distal to the vertebral PICA junction. We treated the patient conservatively. Four days later, he suddenly fell into a coma, but CT showed no bleeding. Because of this we suspected brain stem ischemia due to deterioration of vertebral dissection. The patient died 8 hours after the ischemic reattack. We report difficulty of treatment of a dissecting vertebral aneurysm with simultaneous ischemia and subarachnoid hemorrhage.     

Embolization for aneurismal dilatation associated with ruptured dissecting anterior inferior cerebellar artery aneurysm with preservation of the parent artery: case report

We report a rare case of a ruptured dissecting anterior inferior cerebellar artery (AICA) aneurysm treated by endosaccular embolization with a Guglielmi detachable coil (GDC). An 85-year-old female presented with headache. Computed tomographic (CT) scan showed subarachnoid hemorrhage and intraventricular hemorrhage in the fourth ventricule. Cerebral angiography and 3D-CT angiography revealed an aneurysmal dilatation at the anterior pontine segment of the right AICA with a diagnosis of arterial dissection. The right posterior inferior cerebellar artery (PICA) was absent and the right AICA supplied the territory normally nourished by the right PICA. The aneurismal dilatation was occluded by endosacullar embolization with preservation of the AICA. The distal AICA aneurysm is rare and only seven cases treated with endovascular embolization have been reported. In these, six cases were treated by parent artery occlusion with coil and the subsequent three cases presented with ischemic complications. Only one case was treated by endosaccular embolization with GDC. To our knowledge, this is the second report of the distal AICA aneurysm treated by endosaccular embolization with GDC. Distal AICA aneurysms are briefly discussed while reviewing the literature.     

Dissecting aneurysm of the posterior inferior cerebellar artery--studied by serial angiography]

We report the case of a 34-year-old male with cerebellar hemorrhagic infarction caused by a dissecting aneurysm of the left posterior inferior cerebellar artery (PICA). The patient suffered from a headache and vomiting for two days and was transferred to our hospital with sudden deterioration of consciousness. On admission, he was semicomatose. A CT scan revealed hemorrhagic infarction in the left cerebellum and upward herniation. The emergency operation for posterior fossa decompression was performed. Postoperatively, his consciousness level improved promptly and he had no neurological deficits except for slight gait disturbance. The first vertebral angiography was performed on Day 27. It showed a sausage-like dissecting aneurysm of the left distal PICA. We planned conservative therapy with careful observation because of there being no indication for an operation. Serial angiography was performed and demonstrated the regression of the dissecting aneurysm on Day 258. Dissecting aneurysms of the distal PICA are rare and their natural history is not well understood. Conservative therapy for vertebrobasilar dissecting aneurysms has often been reported. We suggest that conservative therapy with serial angiography is the treatment of choice especially for ischemic-type dissecting aneurysms. We review 17 cases of dissecting aneurysm of the distal PICA in this study.     

Fusiform vertebral artery aneurysms as a cause of dissecting aneurysms. Report of two autopsy cases and a review of the literature.

Two autopsy cases of angiographically determined fusiform aneurysms of the vertebral arteries (VAs) are reported and the appropriate literature is reviewed to investigate the pathological characteristics of both fusiform and dissecting VA aneurysms and the pathogenesis of dissecting aneurysms. One patient had suffered a subarachnoid hemorrhage (SAH) due to dissection of a previously documented incidental fusiform aneurysm. The other patient had harbored incidental fusiform aneurysms coexistent with a ruptured aneurysm of the posterior inferior cerebellar artery. The location and pathological features of the aneurysms were similar in the two cases. The aneurysms in both cases displayed intimal thickening, disruption of the internal elastic lamina, and degeneration of the media. A mural hemorrhage and patchy calcification were also found in the case that included SAH. Based on their pathological investigation of these two cases and a review of reported cases, the authors propose that incidental fusiform aneurysms in the VAs are characterized by weakness in the internal elastic lamina and, therefore, have the potential to become dissecting aneurysms, resulting in a fatal prognosis. This suggests that long-term control of blood pressure is mandatory in patients with incidental fusiform aneurysms in the VAs.     

Aneurysm at the posterior inferior cerebellar artery of extradural origin for preoperative evaluation of safe clipping: case report and review of the literature

BACKGROUND: As far as we know, 6 cases of extracranial (including craniocervical junction) intradural aneurysms of the posterior inferior cerebellar artery have been previously reported. However, preoperative detailed evaluation of the origin site and a course of the posterior inferior cerebellar artery by means of angiography were not reported in previous papers. CASE DESCRIPTION: We report a rare case of aneurysm of the posterior inferior cerebellar artery, which originated extradurally from the right vertebral artery. A 69-year-old woman experienced a sudden headache 16 years ago and a computed tomography scan showed a subarachnoid hemorrhage around the midbrain. Four-vessel cerebral angiography, however, failed to disclose a source of the hemorrhage. Magnetic resonance angiography incidentally revealed an aneurysm at the craniocervical junction 16 years after the subarachnoid hemorrhage. The aneurysm was exposed and clipped via a suboccipital route. At surgery, it was of no use to apply a temporary clip on the intradural segment of the vertebral artery, because the posterior inferior cerebellar artery was found to enter the intradural space separately from the vertebral artery. The blood flow to such an aneurysm cannot be stopped with this procedure. CONCLUSIONS: Careful neuroimaging study is essential for the accurate diagnosis and successful treatment of such a rare aneurysm.     

Ruptured vertebral artery dissecting aneurysm followed by spontaneous acute occlusion and early recanalization: case report

A 47-year-old man presented with a ruptured vertebral artery dissecting aneurysm manifesting as subarachnoid hemorrhage followed by acute occlusion and early recanalization of the affected artery. Cerebral angiography 2 hours after the onset of the symptom showed pearl-and-string sign in the right vertebral artery. Serial angiography showed that the affected artery was occluded at 12 hours but was recanalized on the 4th day. The dissecting aneurysm was resected with side-to-side anastomosis between the bilateral posterior inferior cerebellar arteries. Postoperative cerebral angiography demonstrated disappearance of the lesion and patency of the right posterior inferior cerebellar artery via the anastomosis. Histological examination of the lesion showed hematoma between the media and adventitia, disrupting the internal elastica and intima. Acute occlusion and early recanalization of the affected artery may occur in ruptured vertebral artery dissecting aneurysms. Serial neurological and neuroradiological examinations are essential to decide the timing and method of treatment.     

Ruptured pseudoaneurysm following Gamma Knife surgery for a vestibular schwannoma

A 75-year-old woman underwent Gamma Knife surgery (GKS) for a vestibular schwannoma. Eight years after GKS, she suffered sudden onset of headache. Computed tomography revealed diffuse subarachnoid hemorrhage around the cisterns of the posterior fossa. Right vertebral artery angiography showed an aneurysm arising from the lateral pontomedullary segment of the left anterior inferior cerebellar artery. The aneurysm was not located at a branching site. Trapping of the distal anterior inferior cerebellar artery aneurysm was performed, and the aneurysm was removed. The pathological features of this aneurysm are discussed. This aneurysm was diagnosed as a pseudoaneurysm pathologically. This is the first report of aneurysm formation with pathological findings following GKS for a vestibular schwannoma.     

Serial angiographical changes of a ruptured dissecting vertebral aneurysm

A 54-year-old woman presented a subarachnoid hemorrhage from a ruptured dissecting aneurysm on the right vertebral artery. A right vertebral angiogram revealed a fusiform dilatation distal to the right posterior inferior cerebellar artery and "pseudo lumen" was observed in a delayed arterial phase. Conservative treatment was carried out, and the patient condition gradually improved. An angiographical examination for planned endovascular treatment 46 days after the onset, revealed the normalization of the formerly dilated caliber of the right vertebral artery with only a minor luminal irregularity. However, 83 days after the onset, right vertebral angiogram showed reappearance of the fusiform dilatation. The right vertebral angiogram obtained 204 days after the onset showed that the dilated segment of the dissecting aneurysm had become normalized to a slight degree. The serial angiographical changes of the dissecting site might have been due to regression and organization following transient thrombosis of intramural hematoma. Such drastic changes within a short period have not been reported yet. In conclusion, careful repeated follow-up is recommended in monitoring aneurysmal formation during the early to chronic phase after rupture of a dissecting aneurysm. The repetition of angiography is important, because later, if angiography has been performed only once, aneurysmal dilatation may be overlooked. One has to be aware of such changes, because such changes may alter the clinician's decision about treatment, as they did in our case.     

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms

OBJECT: Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation. METHODS: Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically. RESULTS: Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement. CONCLUSIONS: Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.     

Late morphological progression of a dissecting basilar artery aneurysm after staged bilateral vertebral artery occlusion: case report

BACKGROUND: The authors present a patient who experienced late (5-year follow-up) morphological progression of a dissecting aneurysm of the distal basilar artery after treatment with a combined microsurgical and neuroendovascular Hunterian strategy. In addition to postulating about the possible reasons underlying the evolution of this lesion, the role of stenting is discussed. CASE DESCRIPTION: The patient was 37 years old when she suffered a subarachnoid hemorrhage from spontaneous basilar artery dissection. At the time of the hemorrhage, minimal aneurysmal enlargement was noted angiographically, and she was therefore treated nonoperatively. On reimaging 5 months later, massive enlargement of the aneurysm was noted. The patient was treated with staged bilateral vertebral artery sacrifice using a combination of microsurgical and neuroendovascular techniques. The dominant vertebral artery was clip-ligated distal to the posteroinferior cerebellar artery, whereas the contralateral vertebral artery was coil-occluded cervically 1 week later. CONCLUSIONS: Despite the patient remaining asymptomatic, follow-up angiography 5 years after the initial hemorrhage revealed further enlargement of the aneurysm as well as a newly discovered inferiorly projecting daughter sac measuring 5 mm in diameter. Clearly, certain aneurysms exist for which indirect approaches involving hemodynamic attenuation fail to prevent progression. With greater refinements in stent technology, such lesions may be more effectively treated.     

Persistent Patent Pseudolumen of Ruptured Dissecting Aneurysm Involving the Posterior Inferior Cerebellar Artery After Proximal Clipping

Summary  In the majority of cases of ruptured vertebral artery dissecting aneurysm after proximal clipping, the dissected pseudolumen persists for a very short time, probably because re-entry from the pseudolumen is minimal. Recent reports have indicated a high risk of rebleeding of dissecting aneurysms involving the posterior inferior cerebellar artery (PICA) after proximal clipping, probably due to excessive retrograde flow from the distal vertebral artery into both the PICA and the pseudolumen. We describe an extremely rare case of ruptured dissecting aneurysm involving the PICA with persistent patent pseudolumen after proximal clipping. The present case was assumed to have developed a moderate retrograde flow just sufficient to maintain the patent pseudolumen in the chronic stage. Neo-intimal formation is suggested to be a possible mechanism by which the pseudolumen is stabilized for a very long period.     

Giant, fusiform and dissecting aneurysms at the vertebro-basilar junction--report of five cases and their clinical pathophysiological aspects

Five cases of giant, fusiform, and dissecting aneurysms of the vertebro-basilar junction, in which direct surgical treatment was not feasible, are reported. Their initial symptoms were as follows: 3 subarachnoid hemorrhages (2 fusiform aneurysms, 1 giant aneurysm), 1 mass sign (giant aneurysm), and 1 ischemic sign (dissecting aneurysm). In two patients, one with a giant and one with a dissecting aneurysm, preoperative proximal vertebral occlusion was carried out by inflated balloon for 30 to 100 minutes, under observation of clinical signs and measurement of distal arterial pressure. This catheter technique with an inflated balloon provides the means to assess the effect of vertebral artery occlusion in the alert patient, and to determine if occlusion is tolerated or not. In one case with a giant aneurysm, the proximal vertebral artery was occluded extracranially with no complications and no recurrent subarachnoid hemorrhage for 1 year. The other four patients (1 thrombosed giant aneurysm, 2 fusiform aneurysms, 1 dissecting aneurysm) whose contralateral vertebral arteries were hypoplastic, and who refused to operation, were treated conservatively for 6 months to 6 years. Their outcomes were better than expected, with no recurrent subarachnoid hemorrhage nor aggravation of clinical symptoms except for the one case with a dissecting aneurysm whose deterioration was presumed attributable to late cerebellar cortical atrophy.     

Recurrence of a vertebral artery dissecting pseudoaneurysm after successful stent-supported coil embolization: case report

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed. CLINICAL PRESENTATION: A 36-year-old man with a remote history of head injury had recovered functionally to the point of independent living. He experienced the spontaneous onset of severe head and neck pain, which progressed rapidly to obtundation. A computed tomographic scan of the head revealed subarachnoid hemorrhage centered in the posterior fossa. The patient underwent cerebral angiography, which revealed dilation of the distal left vertebral artery consistent with a dissecting pseudoaneurysm. INTERVENTION: Transfemoral access was achieved under general anesthesia, and two overlapping stents (3 mm in diameter and 14 mm long) were placed to cover the entire dissected segment. Follow-up angiography of the left vertebral artery showed the placement of the stents across the neck of the aneurysm; coil placement was satisfactory, with no residual aneurysm filling. Approximately 6 weeks after the patient's initial presentation, he developed the sudden onset of severe neck pain. A computed tomographic scan showed no subarachnoid hemorrhage, but computed tomographic angiography revealed that the previously treated left vertebral artery aneurysm had recurred. Angiography confirmed a recurrent pseudoaneurysm around the previously placed Guglielmi detachable coils. A test balloon occlusion was performed for 30 minutes. The patient's neurological examination was stable throughout the test occlusion period. Guglielmi detachable coil embolization of the left vertebral artery was then performed, sacrificing the artery at the level of the dissection. After the procedure was completed, no new neurological deficits occurred. On the second day after the procedure, the patient was discharged from the hospital. He was alert, oriented, and able to walk. CONCLUSION: We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.     

Bilateral anomalous posterior inferior cerebellar artery-anterior inferior cerebellar artery anastomotic arteries associated with a ruptured cerebral aneurysm--case report

A 50-year-old man presented with subarachnoid hemorrhage from a ruptured cerebral aneurysm arising from a left posterior inferior cerebellar artery (PICA)-anterior inferior cerebellar artery anastomotic artery manifesting as severe headache, obtundation, and quadriplegia. Conventional and three-dimensional digital subtraction angiography showed that the anastomotic complex was present bilaterally and both vertebral arteries terminated at the origin of the PICA. The identification of this anomalous vascular network allowed coil embolization of the broad-based aneurysm with occlusion of the parent artery. The patient had residual moderate disturbance of consciousness and quadriplegia before transfer for rehabilitation.     

Dissecting Aneurysm of the Peripheral Posterior Inferior Cerebellar Artery

Dissecting aneurysms of intracranial posterior circulation have recently been shown to be less uncommon than previously thought. However, those involving the posterior inferior cerebellar artery (PICA) and not vertebral artery at all are extremely rare. We report here a case of a patient with a dissecting aneurysm of the lateral medullary segment of PICA which presented as subarachnoid haemorrhage. The aneurysm was treated by trapping surgery and the distant PICA was anastomosed to the occipital artery. The patient showed a slight ataxia immediately after surgery but recovered fully. Recovery from immediately postoperative cerebellar symptoms due to intra-operative ischemia seemed to be due largely to recovery of flow in the region of cortical branches of PICA.