Complex vertebral arteriovenous fistula and ruptured aneurysm in neurofibromatosis: a therapeutically challenging case

The objective and importance of this study was to describe the challenges encountered with treating a high-flow vertebral arteriovenous fistula (AVF) and ruptured aneurysm in a patient with life-threatening hemorrhage. A 36-year-old female with Neurofibromatosis type 1 (NF1) presented 2 weeks after uneventful cesarean section with a rapidly expanding pulsatile neck mass. Angiography demonstrated a complex left vertebral AVF and multiple associated vertebral artery aneurysms. Emergent endovascular coil embolization was performed using a retrograde and antegrade approach to occlude the fistulas and trap the ruptured aneurysm, successfully treating the acute hemorrhage. Subsequent definitive therapy was accomplished utilizing a combined neurointerventional and neurosurgical strategy of direct-puncture acrylic embolization and ligation of the vertebral artery. Recent advances in neurointerventional technology allow novel approaches in the primary and/or preoperative treatment of complex vascular lesions such as those seen in NF1.     

Ruptured anterior communicating artery aneurysm associated with anterior cranial fossa dural arteriovenous fistula--case report

A 77-year-old man presented with an extremely rare association of anterior cranial fossa dural arteriovenous fistula (AVF) with anterior communicating artery (ACoA) aneurysm manifesting as consciousness deterioration due to intracerebral hemorrhage in the left frontal lobe and diffuse subarachnoid hemorrhage. Angiography confirmed the association of a dural AVF fed by both ethmoidal arteries and an ACoA aneurysm. Surgery for these two lesions was performed concurrently, and the ACoA aneurysm was found to be responsible for the hemorrhage. This association seems incidental, but is clinically significant since the preoperative determination of the bleeding point is difficult. We conclude that these two lesions should be treated simultaneously, to avoid leaving the ruptured point untreated.     

Cerebellar hemorrhage after coil embolization for a ruptured vertebral dissecting aneurysm

BACKGROUND: We present a case of ruptured vertebral dissecting aneurysm that exhibited cerebellar hemorrhage after successful embolization of the vertebral artery including the dissected site. CASE PRESENTATION: A 59-year-old man suffered a sudden onset of severe occipital headache when he looked up. Computed tomography demonstrated subarachnoid hemorrhage. Angiography revealed a right vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery. Endovascular embolization of the aneurysm was performed with preservation of the posterior inferior cerebellar artery. The next day, the patient suffered a cerebellar hemorrhage in the vermis. The intracranial pressure was controlled by external ventricular drainage. The patient was discharged with mild cerebellar ataxia and bilateral abducens nerve palsy. CONCLUSION: In a case of vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery, blood circulation in the vertebral arterial system may change after embolization of the aneurysm. In our case, the preserved posterior inferior cerebellar artery might have been hemodynamically stressed postoperatively, resulting in cerebellar hemorrhage. Therefore, strict control of blood pressure is essential in the acute stage after occlusion of the aneurysm.     

Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with Guglielmi detachable coils

BACKGROUND: Fenestration of vertebrobasilar junction is a rare congenital anomaly and often associated with aneurysm formation. We describe five cases of vertebrobasilar junction aneurysms in four patients associated with fenestration, which were treated with endovascular coil occlusion using Guglielmi detachable coils (GDCs). The importance of preoperative computed tomography (CT) angiography to understand the complex anatomy of fenestration and aneurysm is emphasized. CASE REPORTS: Three patients presented with subarachnoid hemorrhage and one patient presented with headache only. Among 3 patients with subarachnoid hemorrhage, 1 patient was referred for endovascular coil occlusion after clipping of ruptured distal ACA aneurysm. A six-French guiding catheter was placed in the left vertebral artery via right femoral artery, except for 1 patient who had two vertebrobasilar junction aneurysms with complex anatomic relationship, accessed bilaterally. Five vertebrobasilar junction aneurysms with fenestration were treated with endovascular coil occlusion using GDCs. Postoperative angiography demonstrated successful occlusion of aneurysmal sac with preservation of basilar artery. CONCLUSIONS: Vertebrobasilar junction aneurysms are frequently associated with fenestrations. In addition to vertebral angiography on both sides, CT angiography may be a valuable tool for better understanding of complex anatomy of aneurysms associated with fenestration. The surgically difficult aneurysms such as vertebrobasilar junction aneurysm with fenestration can be successfully treated with GDCs.     

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.     

Case of spontaneous bilateral VA dissecting aneurysm presenting with SAH

We report a case of bilateral vertebral artery (VA) dissecting aneurysm presenting subarachnoid hemorrhage (SAH). It was difficult to decide which side was responsible for SAH because the patient's symptom and head CT suggested that the left VA aneurysm had ruptured, but angiography and MRA showed an irregular pearl and string sign on the right side. He was successfully treated by trapping of the right VA dissecting aneurysm and we confirmed by intraoperative evaluation that the right VA dissecting aneurysm had ruptured. The left unruptured aneurysm decreased its size spontaneously. In the treatment of the bilateral VA dissecting aneurysms, angiography needs to be performed over and over again because contralateral unruptured aneurysm may grow or rupture due to increased hemodynamic stress. Various combinations of direct sugery with or without arterial reconstruction and endovascular treatment should be considered when treating bilateral VA dissecting aneurysms.     

Aneurysm of the distal posteroinferior cerebellar artery of extracranial origin: case report

OBJECTIVE AND IMPORTANCE: We describe a very rare case involving a ruptured intracranial aneurysm at the distal posteroinferior cerebellar artery (PICA) branching from the extracranial vertebral artery. CLINICAL PRESENTATION: A 53-year-old woman experienced the sudden onset of a severe occipital headache and vomiting. Computed tomographic scanning revealed subarachnoid and intraventricular hemorrhage. Cerebral angiography of the left vertebral artery demonstrated the left PICA branching from the extracranial segment of the extracranial vertebral artery at the level of C2; a saccular aneurysm arose from the intracranial portion of the distal PICA. INTERVENTION: Via the transcondylar approach, we were able to obtain adequate visualization without retracting important structures. To avoid injury to the anomalous PICA, the aneurysm was clipped. CONCLUSION: Only four other cases of a distal aneurysm of the PICA branching from the extracranial vertebral artery have been reported in the literature. In all cases, the aneurysm originated at the intradural extracranial portion of the PICA. To our knowledge, the case presented here is the first report of a ruptured aneurysm at the level of the intracranial portion of the PICA branching from the extracranial segment of the vertebral artery.     

Isolated intraventricular hemorrhage due to a ruptured vertebral artery aneurysm

A rare case of ruptured aneurysm originating from the vertebral artery, and presenting an isolated clot in the fourth ventricle is reported. The patient underwent surgery via a right lateral suboccipital craniectomy on the third day. As the aneurysm was huge and partially thrombosed, trapping was performed and completed successfully. If isolated intraventricular hematoma was found without obvious parenchymal hemorrhage or subarachnoid clot, the diagnosis of vertebral artery aneurysm should be considered as a possibility in addition to posterior inferior cerebellar artery aneurysm. Complete vertebral angiography is indispensable for the recognition of this condition.     

Dissecting aneurysm of basilar artery presenting with recurrent subarachnoid hemorrhage

Spontaneous basilar dissecting aneurysms secondary to subarachnoid hemorrhage are rare, usually presenting with ischemia rather than a subarachnoid hemorrhage (SAH). A 63-year-old man who had SAH repeatedly from a ruptured basilar dissecting aneurysm was treated with endovascular occlusion of the unilateral vertebral artery. Postoperative angiograms 1 month after the procedure showed complete obliteration of the aneurysm. The clinical follow-up at 20 months showed no evidence of recurrent hemorrhage. Received: 24 August 1998 / Accepted: 15 December 1998     

Vertebral arteriovenous fistula that developed in the same place as a previous ruptured aneurysm: a case report

BACKGROUND: Aneurysms of the extracranial vertebral artery (VA) and vertebral arteriovenous fistulas (VAVFs) are relatively rare diseases. The most frequent cause of both diseases is trauma. Atraumatic lesions are less common. Presented here is a case of atraumatic AVF of the extracranial VA that developed in the same location as a previous ruptured aneurysm of the ipsilateral VA that was originally treated by proximal occlusion 11 years earlier. METHODS: A 40-year-old woman presented with a massive hematoma in the upper posterior neck region caused by the rupture of an extracranial VA aneurysm. Proximal occlusion of the VA was performed by use of a detachable balloon. She enjoyed good health for 11 years, then she noticed a pulsatile bruit. Angiograms revealed an AVF between the left VA that was fed by collateral circulation and the paravertebral venous plexus. Incidentally found were soft tissue masses in the left retroauricular and the right suboccipital regions. Also, skull X-ray films showed multiple bony defects. Biopsy of the subcutaneous mass was performed in the hope of obtaining clues as to which pathological processes had weakened the artery. RESULTS: As direct transarterial access to the fistula was out of the question, the fistulous compartment of the paravertebral venous plexus was tightly packed with multiple platinum coils effected by the transfemoral approach. A histological examination of the specimen revealed features of a neurofibroma, and a diagnosis of neurofibromatosis Type 1 was established. CONCLUSIONS: In this case, transvenous embolization of the VAVF was successfully performed. The fragility of the arterial wall, related to neurofibromatosis Type 1, was considered to contribute to the development of the aneurysm and AVF.     

Deformation of the ventrolateral medulla oblongata by subarachnoid hemorrhage from ruptured vertebral artery aneurysms causes neurogenic pulmonary edema.

The occurrence of neurogenic pulmonary edema (NPE) associated with subarachnoid hemorrhage (SAH) due to ruptured aneurysm was analyzed in 48 consecutive patients. Correlations of the location of the aneurysm, clinical grade, amount of subarachnoid clot, and severity of NPE were examined. NPE was observed in 29.4% of all SAH cases, but the incidence was significantly higher in cases of ruptured vertebral artery (VA) aneurysm. Clinical grade, severity of NPE, and deformation of the medulla oblongata were studied in the five cases of ruptured VA aneurysm. Deformation of the ventrolateral medulla oblongata was observed in all patients. Asymmetry index of the medulla oblongata measured on the axial computed tomography scan was correlated with the severity of NPE. Severity of NPE tended to correlate with deformation of the medulla oblongata. NPE associated with ruptured VA aneurysm is caused by deformation of the ventrolateral site of the medulla oblongata by the localized hemorrhage.     

Vitreous hemorrhage as a complication of subarachnoid hemorrhage (Terson's syndrome) (author's transl)

We represent a case of vitreous hemorrhage due to subarachnoid hemorrhage from a ruptured aneurysm of the right vertebral artery to draw attention to this complication. A 53-year-old man was admitted to our hospital because of generalized headache and reduced visual acuity of both eyes. On admission the patient was alert and there were moderate nuchal stiffness and mild symmetrical hyperreflexia in the extremities. Ophthalmological consultation revealed bilateral retinal, subhyaloid and vitreous hemorrhages. Four-vessel angiography demonstrated an aneurysm of the right vertebral artery. At operation, it became clear that the aneurysm was a dissecting one. The vertebral artery was clipped at the most proximal intracranial portion. Postoperative course was smooth and uneventful except deteriorated visual acuity. His visual acuity deteriorated continuously to hand movements 18 days after subarachnoid hemorrhage. His visual acuity, however, gradually improved without specific treatment. At the time of this writing, his visual acuity is 1.0 on both sides. Vitreous hemorrhage is a rare complication following a reptured aneurysm. Pertinent literature concerning fundal hemorrhage, especially vitreous hemorrhage, associated with subarachnoid hemorrhage suggests that it may occur as a result of sudden increase of intracranial pressure.     

A case of neurofibromatosis type 1 associated with arteriovenous fistula caused by re-bleeding of a vertebral dissecting aneurysm

We described a dissecting aneurysm of the vertebral artery (VA), which was associated with neurofibromatosis type 1 (NF1). A 41-year-old man was referred to our hospital because of abrupt, severe headache. A CT scan revealed diffuse subarachnoid hemorrhage (SAH) predominantly in the prepontine cistern. The angiograms showed a string sign in the left VA, just distal to the posterior inferior cerebellar artery (PICA). The vertebral dissection was considered responsible for SAH, and endovascular occlusion of the left VA was attempted. During the intervention, the patient complained of severe neck pain at the time of selective vertebral angiography, which revealed an arteriovenous fistula. The VA was occluded proximal to the PICA with GDC, which covered the fistula. Open surgery confirmed the two unruptured aneurysms. Intracranial dissection is rarely reported in association with NF1. However, ateriovenous fistula is not an uncommon combination with dissecting aneurysm and the extracranial segment of the VA is a characteristic target. Anatomical feasibility is conceivably the pathogenesis.     

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.     

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.     

Acute occlusion and recanalization of vertebral artery dissection after subarachnoid hemorrhage: usefulness of bilateral simultaneous vertebral angiography and basiparallel anatomic scanning-magnetic resonance imaging. Case report

A 41-year-old man presented with subarachnoid hemorrhage. Initial digital subtraction angiography showed occlusion of the right vertebral artery (VA), which recanalized immediately, and dissecting aneurysm on the distal part of the right VA. Basiparallel anatomic scanning (BPAS)-magnetic resonance (MR) imaging showed the morphology of the aneurysm clearly. Coil embolization of the entire affected artery was performed using bilateral vertebral angiography road mapping. Although acute occlusion of ruptured VA dissection may have the potential for natural healing, spontaneous recanalization seems to be hazardous because of rebleeding. In cases with acute occlusion of parent artery, BPAS-MR imaging and bilateral simultaneous vertebral angiography may give useful information.     

Ruptured internal carotid -posterior communicating artery aneurysm associated with an anomalous hyperplastic anterior choroidal artery and aneurysm: case report

We report a rare case of a ruptured internal carotid-posterior communicating artery (IC-PcomA) aneurysm associated with an anomalous hyperplastic anterior choroidal artery (AchoA) and aneuysm. A 64-year-old woman was admitted to our hospital because of a sudden onset of headache. CT scan showed subarachnoid hemorrhage. Left internal carotid angiograms showed a saccular aneurysm at the IC-PcomA region. Left posterior cerebral artery filling from the fetal type PcomA and an anomalous hyperplastic AchoA originating from the internal carotid artery (ICA) were also revealed. Left vertebral angiograms (Allcock test) revealed the left ICA and an anomalous hyperplastic AchoA via the fetal type PcomA. The patient was surgically treated through the left pterional transsylvian approach. The ruptured aneurysm was observed at the IC-PcomA region. The unruptured small aneurysm was found on just distal to the ruptured aneurysm. The PcomA and an anomalous hyperplastic AchoA were not observed behind the ICA. To prevent bleeding, the ruptured aneurysm and unruptured small aneurysm were clipped. Postoperative left internal carotid angiograms demonstrated no aneurysm was observed at the IC-PcomA region. The patency of the fetal type PcomA and an anomalous hyperplastic AchoA were preserved. The 7 reported cases of a intracranial aneurysm associated with an anomalous hyperplastic AchoA with our case are reviewed and their neuroradiological and clinical features are discussed.     

Case of a ruptured vertebral artery dissecting aneurysm recanalized after internal trapping

A 35-year-old male experienced a sudden onset of severe headache. A CT scan revealed subarachnoid hemorrhage. By cerebral angiography, he was diagnosed as having a ruptured right vertebral artery dissecting aneurysm (VADA). It was successfully treated by endovascular occlusion of the affected site, including the aneurysm and parent artery, by using detachable coils. A follow-up angiography obtained seven months after the first treatment revealed the recanalization of the right vertebral artery and dissected aneurysm in an antegrade fashion. A skull X-ray image was useful for detecting the change in appearance of the coils. The second embolization was successfully performed in the same manner. Based on this rare case, the authors emphasize that a careful angiographic analysis and complete internal trapping of the dissecting site are important in the treatment of the ruptured VADA.     

De novo dissecting aneurysm in a patient with a ruptured saccular lesion. Case report

Formation of a new saccular aneurysm after successful treatment of ruptured aneurysm has recently raised significant clinical concerns; however, de novo formation and rupture of a dissecting aneurysm has not been discussed. The authors report on a 42-year-old man who initially sought treatment for a ruptured saccular aneurysm of the right middle cerebral artery, which was successfully eliminated by surgical clipping of the aneurysm neck. Two years later, the patient presented with another subarachnoid hemorrhage and was found to have a dissecting aneurysm of the right vertebral artery, which arose from a previously angiographically documented normal artery. This rare association sheds light on the causes and growth of two distinct types of aneurysms, both clinically and pathologically.     

Two cases of spinal arteriovenous malformation presenting with subarachnoid hemorrhage

Two cases of spinal arteriovenous malformation (AVM) with subarachnoid hemorrhage (SAH) are reported. The first case is that of a 14-year-old boy who was transferred to our hospital with a sudden onset of headache. Neurological examination revealed no motosensory deficit, but a brain CT showed a slight diffuse SAH. A left vertebral angiogram demonstrated intramedullary AVM in the cervical region of the spinal cord. This AVM was therefore occluded using a solid embolization material. The patient was then discharged without neurological deficit. The second case is that of a 67-year-old man who visited our hospital with a sudden onset of headache. Neurological examination revealed no motor or sensory deficit, but a brain CT showed SAH, which was dominant in the posterior fossa. Initial cerebral angiography demonstrated no abnormality such as cerebral aneurysm or AVM except for laterality of the C1 radiculo-meningeal artery. A second angiogram on day 11 demonstrated spinal arteriovenous fistula (AVF), which was fed by the left radiculo-meningeal artery and drained to the posterior spinal vein. Embolization for the AVF was performed using liquid material. He was then discharged without neurological deficit. These two cases revealed non-specific SAH symptoms and were indistinguishable from other ruptured aneurysms. Although the brain CT can show a slight SAH or posterior fossa dominant SAH, repeated angiography may be necessary to verify and conclude the diagnosis of spinal AVM.