J Korean Neurosurg Soc.  2012 Mar;51(3):155-159. 10.3340/jkns.2012.51.3.155.

Bilateral Vertebral Artery Dissecting Aneurysms Presenting with Subarachnoid Hemorrhage Treated by Staged Coil Trapping and Covered Stents Graft

• Yoon SM
• Shim JJ
• Kim SH
• Chang JC

• KMID: 2018190
• DOI: http://doi.org/10.3340/jkns.2012.51.3.155

Abstract

The treatment of bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid hemorrhage (SAH) is still challenging. The authors report a rare case of bilateral VADA treated with coil trapping of ruptured VADA and covered stents implantation after multiple unsuccessful stent assisted coiling of the contralateral unruptured VADA. A 44-year-old woman was admitted to our hospital because of severe headache and sudden stuporous consciousness. Brain CT showed thick SAH and intraventricular hemorrhage. Cerebral angiography demonstrated bilateral VADA. Based on the SAH pattern and aneurysm configurations, the right VADA was considered ruptured. This was trapped with endovascular coils without difficulty. One month later, the contralateral unruptured VADA was protected using a stent-within-a-stent technique, but marked enlargement of the left VADA was detected by 8-months follow-up angiography. Subsequently two times coil packing for pseudosacs resulted in near complete occlusion of left VADA. However, it continued to grow. Covered stents graft below the posterior inferior cerebellar artery (PICA) origin and a coronary stent implantation across the origin of the PICA resulted in near complete obliteration of the VADA. Covered stent graft can be used as a last therapeutic option for the management of VADA, which requires absolute preservation of VA flow.

Keyword

Vertebral artery dissecting aneurysm; SAH; Stent assisted coiling; Trapping; Covered stent graft; Endovascular embolization

MeSH Terms

Adult
Aneurysm
Aneurysm, Dissecting
Angiography
Arteries
Brain
Cerebral Angiography
Consciousness
Female
Follow-Up Studies
Headache
Hemorrhage
Humans
Pica
Stents
Stupor
Subarachnoid Hemorrhage
Transplants
Vertebral Artery

Figure

• 

  Fig. 1 Pre- and post-operative radiologic images in a 44-year-old woman presenting with SAH. Brain CT (A) shows thick SAH on basal, prepontine, and both cerebellopontine angle cisterns, and acute hydrocephalus due to intraventricular hemorrhage. Preoperative digital subtraction angiography (B) and 3-dimensional rotational angiogram (C) demonstrate a 6×12 mm sized right VADA (the right PICA is not visualized), and a 5×7 mm sized left VADA, which is incorporated with PICA origin. Postoperative vertebral angiograms after packing of 19 coils for right VADA show complete trapping of the right VADA with sufficient flow to the basilar artery via the left vertebral artery (D and E). Vertebral angiogram after double stent implantation for the left VADA demonstrates slightly reduced blood flow to the aneurysmal sac (F). SAH : subarachnoid hemorrhage, VADA : vertebral artery dissecting aneurysm, PICA : posterior inferior cerebellar artery.

• 

  Fig. 2 Follow-up vertebral angiograms at 8 months after double overlapping stenting on the left VADA showing stable occlusion of right VADA (A) and marked growth of the left VADA (B). Postoperative left vertebral angiogram after coil packing into the two different pseudosacs shows near complete obliteration of left VADA, while sparing left PICA flow (C). VADA : vertebral artery dissecting aneurysm, PICA : posterior inferior cerebellar artery.

• 

  Fig. 3 Follow-up left vertebral angiogram (A) at 5 months after coil packing of the left VADA demonstrating its further growth. Postoperative skull radiograph (B) shows triple overlapping stents and coil mass on the left vertebral artery after further coil packing of the two growing pseudosacs and bailout stenting using an Enterprise stent. White arrows indicate proximal and distal end of the triple stents. Postoperative angiograms (C and D) show near complete obliteration of the VADA and sparing of left PICA flow. VADA : vertebral artery dissecting aneurysm, PICA : posterior inferior cerebellar artery.

• 

  Fig. 4 Follow-up angiograms at 4 months after final embolization also showing left VADA regrowth (A). Postoperative skull radiograph after telescopic stenting with two covered stents graft (Graftmaster 3.5×12 mm, 3.5×9 mm) on the left vertebral artery just below the PICA origin and a third stent (Driver 3.5×12 mm) across the PICA origin (B). Arrows indicate the proximal end of covered stent and distal end of Driver stent. Final vertebral angiograms at early arterial (C) and late arterial phase (D) still demonstrate slow retrograde flow to VADA, although flow velocity into the VADA is markedly decreased. Follow-up angiograms 2 month later show near complete occlusion of the left VADA (E and F). VADA : vertebral artery dissecting aneurysm, PICA : posterior inferior cerebellar artery.

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