J Cerebrovasc Endovasc Neurosurg.  2022 Mar;24(1):63-72. 10.7461/jcen.2022.E2021.07.002.

Giant vertebral artery aneurysms presenting acutely with WFNS grade five subarachnoid haemorrhage, report of 4 cases treated with endovascular or surgical proximal parent artery occlusion achieving good functional outcome

• Ng PY

• KMID: 2527597
• DOI: http://doi.org/10.7461/jcen.2022.E2021.07.002

Abstract

Ruptured giant aneurysms in the posterior circulation with poor grade subarachnoid haemorrhage (SAH) are associated with poor outcome. In this report four patients with ruptured giant vertebral artery aneurysms who presented acutely with World Federation of Neurosurgical Societies (WFNS) grade five SAH are reviewed. All 4 cases required intubation and ventilation on arrival. Brainstem reflexes were intact in all of them. Early endovascular parent artery coil occlusion was done in two cases. Two other cases were treated with early surgical proximal parent artery clip occlusion. Two cases required ventriculoperitoneal shunting. All cases achieved good recovery with full functional independent outcome at two years follow up. MR angiogram at two years documented resolution of aneurysms. In conclusion good outcome may be possible in some cases of ruptured giant vertebral artery aneurysms with WFNS grade five SAH.

Keyword

Giant aneurysm; Vertebral artery; Parent artery occlusion

Figure

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  Fig. 1. Axial CT at presentation showed hyperdense lesion (outlined by arrows) 49 mm in length which may represent haematoma or giant aneurysm. CT, computed tomography.

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  Fig. 2. (A) Left vertebral artery angiogram AP view showed left vertebral artery giant aneurysm and PICA origin distal to aneurysm. (B) Left vertebral artery angiogram early arterial phase lateral view showed giant left vertebral artery aneurysm with PICA origin distal to it. AP, anteroposterior; PICA, posterior inferior cerebellar artery.

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  Fig. 3. (A) Post coiling left vertebral artery angiogram AP view showed occlusion of the left vertebral artery with no filling of the aneurysm. (B) Left vertebral artery angiogram post coiling lateral view showed occlusion of the left vertebral artery with no filling of the aneurysm. AP, anteroposterior.

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  Fig. 4. CT axial cut at the same level as Fig. 1. 3 weeks post coiling showed reduction in the size and mass effect of the posterior fossa hyperdensity with CSF spaces opening up. CT, computed tomography; CSF, cerebro-spinal fluid.

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  Fig. 5. (A) CT angiogram axial view showed partially thrombosed right vertebral artery giant aneurysm with severe brainstem compression (arrows mark the outline of the aneurysm). (B) CT angiogram reconstructed AP view showed fusiform aneurysmal dilatation of the right intracranial vertebral artery with widening of the space between the two vertebral arteries due to mass effect of the partially thrombosed aneurysm. The two vertebral arteries are co-dominant. (C) CT angiogram reconstructed lateral view showed irregular fusiform aneurysmal dilatation of the intracranial right vertebral artery. CT, computed tomography; AP, anteroposterior.

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  Fig. 6. MRA at two years follow up showed no filling of right vertebral artery and resolution of aneurysm. MRA, magnetic resonance angiography.

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  Fig. 7. MRI coronal view showed a giant right vertebral artery aneurysm with severe brainstem compression. MRI, magnetic resonance imaging.

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  Fig. 8. (A) Right vertebral artery angiogram lateral view showed partially thrombosed right vertebral artery giant aneurysm with PICA origin distal to it. (B) Right vertebral angiogram AP view showed partially thrombosed right vertebral artery giant aneurysm. PICA, posterior inferior cerebellar artery; AP, anteroposterior.

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  Fig. 9. (A) Postoperative left vertebral artery angiogram lateral view showed no retrograde filling of the right vertebral artery giant aneurysm. Flow in distal right vertebral artery and right PICA was preserved. (B) Postoperative left vertebral artery angiogram AP view showed retrograde filling of distal right vertebral artery and right PICA but no retrograde filling of the original right vertebral artery giant aneurysm. PICA, posterior inferior cerebellar artery; AP, anteroposterior.

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  Fig. 10. (A) Left vertebral artery angiogram AP view showing left vertebral artery giant aneurysm. (B) Left vertebral artery angiogram lateral view showing a giant left vertebral artery aneurysm distal to the PICA origin. AP, anteroposterior; PICA, posterior inferior cerebellar artery.

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  Fig. 11. (A) Left vertebral artery angiogram AP view post coil occlusion showed no filling of the giant aneurysm. Flow in PICA was preserved. (B) Left vertebral artery angiogram lateral view post coil occlusion showed no filling of the giant aneurysm. Flow in PICA was preserved. AP, anteroposterior; PICA, posterior inferior cerebellar artery.

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