J Cerebrovasc Endovasc Neurosurg.  2021 Jun;23(2):145-151. 10.7461/jcen.2021.E2020.11.005.

Proximal basilar artery hemorrhage after submaximal angioplasty for intracranial atherosclerotic disease presenting as a large vessel occlusion treated with pipeline embolization device

• Johnson RM
• Young M
• Guglielmi GN
• Farhat H

• KMID: 2517028
• DOI: http://doi.org/10.7461/jcen.2021.E2020.11.005

Abstract

Iatrogenic vessel perforation from endovascular intervention is a devastating complication that commonly is treated with vessel sacrifice. We present a unique case of an iatrogenic proximal basilar artery perforation after submaximal angioplasty in a 67-year-old male presenting with an acute basilar artery occlusion with underlying intracranial atherosclerotic disease. Telescoping flow-diverting stents were then deployed to reconstruct the vessel wall with resulting active hemorrhage resolution. Our case documents a successful deployment of flow-diverting stents with resolution of active hemorrhage after an iatrogenic basilar artery perforation.

Keyword

Intracranial atherosclerosis, Basilar artery, Iatrogenic disease, Angioplasty

Figure

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  Fig. 1. (A) CT angiography of the head, axial view, demonstrating absence of intravascular contrast in the basilar artery at the level of the pons. (B) 3D-vessel reconstruction of the CT angiogram of the head showing bilateral intracranial vertebral artery occlusion distal to bilateral posterior inferior cerebellar arteries (arrows). CT, computed tomography.

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  Fig. 2. Left (A) and right (B) vertebral artery angiogram demonstrating complete occlusion of the proximal basilar artery just distal to the posterior inferior cerebellar artery origin.

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  Fig. 3. (A) RVA angiogram after first attempt submaximal balloon angioplasty demonstrating residual stenosis of the proximal basilar artery. (B) RVA angiogram after second attempt submaximal balloon angioplasty demonstrating active contrast extravasation from the basilar artery. RVA, right vertebral artery.

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  Fig. 4. (A) Right vertebral artery angiogram demonstrating cessation of contrast extravasation and vessel wall reconstruction after overlapping pipeline embolization device insertion into the basilar artery. (B) Lateral fluoroscopic x-ray demonstrating pipeline embolization devices (arrow).

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  Fig. 5. (A) Post-procedure CT of the head demonstrating a right frontal intraparenchymal hematoma along the entry site of the external ventricular drain, and (B) diffuse subarachnoid hyperdensity in the perimesencephalic and sylvian cisterns likely representative of residual contrast and subarachnoid hemorrhage. CT, computed tomography.

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