J Cerebrovasc Endovasc Neurosurg.  2016 Jun;18(2):115-119. 10.7461/jcen.2016.18.2.115.

Neurological Deterioration after Decompressive Suboccipital Craniectomy in a Patient with a Brainstem-compressing Thrombosed Giant Aneurysm of the Vertebral Artery

• Lee W
• Choo YS
• Kim YB
• Chung J

• KMID: 2354886
• DOI: http://doi.org/10.7461/jcen.2016.18.2.115

Abstract

We experienced a case of neurological deterioration after decompressive suboccipital craniectomy (DSC) in a patient with a brainstem-compressing thrombosed giant aneurysm of the vertebral artery (VA). A 60-year-old male harboring a thrombosed giant aneurysm (about 4 cm) of the right vertebral artery presented with quadriparesis. We treated the aneurysm by endovascular coil trapping of the right VA and expected the aneurysm to shrink slowly. After 7 days, however, he suffered aggravated symptoms as his aneurysm increased in size due to internal thrombosis. The medulla compression was aggravated, and so we performed DSC with C1 laminectomy. After the third post-operative day, unfortunately, his neurologic symptoms were more aggravated than in the pre-DSC state. Despite of conservative treatment, neurological symptoms did not improve, and microsurgical aneurysmectomy was performed for the medulla decompression. Unfortunately, the post-operative recovery was not as good as anticipated. DSC should not be used to release the brainstem when treating a brainstem-compressing thrombosed giant aneurysm of the VA.

Keyword

Decompressive craniectomy; Giant intracranial aneurysm; Neurologic deficits; Thrombosis

MeSH Terms

Aneurysm*
Brain Stem
Decompression
Decompressive Craniectomy
Humans
Intracranial Aneurysm
Laminectomy
Male
Middle Aged
Neurologic Manifestations
Quadriplegia
Thrombosis
Vertebral Artery*

Figure

• 

  Fig. 1 Initial radiographic findings. (A) Computed tomography showed surrounding calcification of the aneurysm wall and (B) magnetic resonance image revealed that the medulla oblongata was squeezed between the aneurysm and occipito-cervical junction.

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  Fig. 2 Cerebral angiography showed fusiform-like dilatation of the right vertebral artery due to the thrombosed sac. The real contour of the aneurysm is indicated by a white circle. (A) Antero-posterior view. (B) Lateral view.

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  Fig. 3 Follow-up radiographic findings. (A) and (B) The aneurysm size was increased due to internal thrombosis after endovascular trapping of the right vertebral artery, medulla oblongata compression of the aneurysm was aggravated. (C) Decompressive suboccipital craniectomy (DSC) with C1 laminectomy was performed. (D) Magnetic resonance image (MRI) showed more angulation of the medulla oblongata posteriorly with dense high signal changes from the medulla to the upper spinal cord compared to pre-DSC MRI. (E) Microsurgical aneurysmectomy was performed for medulla decompression.

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