Elsevier

Surgical Neurology

Volume 70, Issue 3, September 2008, Pages 319-322
Surgical Neurology

Aneurysm
Bilateral vertebral artery dissecting aneurysm with subarachnoid hemorrhage treated with staged bilateral vertebral artery coil occlusion: a case report

https://doi.org/10.1016/j.surneu.2007.04.019Get rights and content

Abstract

Background

Vertebral artery dissecting aneurysm is now increasingly recognized as a cause of posterior circulation stroke in young adults. Here, we report a case of bilateral VADA with SAH, treated by bilateral coil occlusion using GDCs.

Case Description

A 64-year-old woman was admitted to our hospital with consciousness disturbance (Hunt and Kosnik: grade 4). Computed tomography showed diffuse SAH with a thick hematoma in the left C-P angle. Magnetic resonance angiography, 3D-CTA, and cerebral angiography revealed bilateral VADAs. First, the ruptured left VADA involving the PICA and a perforating branch was treated by occluding the lower half of the VADA and the proximal VA with GDCs in the acute stage. Thereafter, the residual VADA and contralateral VADA exhibited enlargement on cerebral angiography and MRA for 2 months after the initial surgery; thus, the right VADA was occluded by GDCs just proximal to the right PICA after confirming BTO tolerance.

Conclusion

Staged bilateral VA coil occlusions combined with BTO may be one of the treatment strategies for bilateral VADA with SAH in cases presenting surgical difficulty due to anatomical factors or severe grade of SAH.

Introduction

Vertebral artery dissecting aneurysm is now increasingly recognized as the cause of posterior circulation stroke in a number of cases in young adults [2], [4], [6]. Vertebral artery dissecting aneurysm is generally unilateral, but rare cases of bilateral VADA have been reported [3], [4], [11], [13], [18], [19]. Such cases may present problems with preoperative identification of the ruptured side and with treatment of the unruptured dissecting aneurysm in the contralateral VA [12], [14]. Here, we report a case of bilateral VADA with SAH successfully treated by staged bilateral VA coil occlusion.

Section snippets

Case description

A 64-year-old woman experienced a sudden onset of severe headache and consciousness disturbance in August 2005. Computed tomography (Fig. 1A) showed diffuse SAH with thick hematoma in the left C-P angle cistern. Magnetic resonance angiography (Fig. 2A) depicted abnormal dilatation of the bilateral VA. Three-dimensional computed tomographic angiography (Fig. 1B) and cerebral angiography (Fig. 3A) revealed a fusiform dilatation of 16.6 mm maximum in diameter with fenestration, involving the

Discussion

Vertebral artery dissecting aneurysm is generally unilateral, but rare cases of bilateral VADAs have been reported [3], [4], [11], [13], [18], [19]. The strategy for treatment of bilateral VADAs with SAH remains controversial; but to prevent rebleeding, VADAs often require surgical interventions such as proximal occlusion, trapping, wrapping, or, more recently, stent-supported coil embolization [6], [9], [12], [17]. Stent-supported coil embolization has become one of the ideal management

References (19)

  • N. Aoki et al.

    Rebleeding from intracranial dissecting aneurysm in the vertebral artery

    Stroke

    (1990)
  • B. el Nakadi et al.

    Vertebral artery dissection: case report

    J Cardiovasc Surg (Torino)

    (1995)
  • L.R. Caplan et al.

    Dissection of the intracranial vertebral artery

    Neurology

    (1988)
  • A.H. Friedman et al.

    Subarachnoid hemorrhage from intracranial dissecting aneurysm

    J Neurosurg

    (1984)
  • T. Funaki et al.

    Bilateral vertebral artery dissection and its chronological changes detected by MR angiography: a case report

    No To Shinkei

    (2004)
  • J. Hamada et al.

    Multimodal treatment of ruptured dissecting aneurysms of the vertebral artery during the acute stage

    J Neurosurg

    (2003)
  • T. Hosoya et al.

    Clinical and neuroradiological features of intracranial vertebrobasilar artery dissection

    Stroke

    (1999)
  • Y. Kubo et al.

    Development of a dissecting aneurysm on the vertebral artery immediately after occlusion of the contralateral vertebral artery: a case report

    Neurosurg Rev

    (1998)
  • P. Lylyk et al.

    Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils

    J Neurosurg

    (2001)
There are more references available in the full text version of this article.

Cited by (18)

  • Ruptured Vertebral Artery Dissecting Aneurysm Concurrent with Spontaneous Cervical Internal Carotid Artery Dissection: A Report of Three Cases and Literature Review

    2017, World Neurosurgery
    Citation Excerpt :

    Vertebral artery dissecting aneurysm (VADA) is a well-known cause of subarachnoid hemorrhage (SAH). Multiple spontaneous dissections with VADAs presenting with SAH are rare, and their management is challenging.1-6 Although most of the reported cases involve bilateral VADAs located in the posterior circulation,1-4 cases of multiple-dissection VADA and anterior circulation are even rarer.5,6

  • Treatment Strategies of Subarachnoid Hemorrhage from Bilateral Vertebral Artery Dissection: A Case Report and Literature Review Focusing on the Availability of Stent Placement

    2017, World Neurosurgery
    Citation Excerpt :

    Cases in which the contralateral side was reported as a de novo dissection10,11 also may have been misdiagnosed initially; therefore, they were included in our literature review. The average age of the 39 patients, including our case, was 47.3 years (32–64 years); there were 17 women and 22 men (Table 1).1,2,4-7,10-12,14,15,19,21-23,26-32 SAH grades were described inconsistently; therefore, we used our discretion to apply WFNS grades.

  • Successful treatment of bilateral vertebral artery dissecting aneurysms with subarachnoid hemorrhage: Report of three cases

    2012, Journal of Stroke and Cerebrovascular Diseases
    Citation Excerpt :

    Therefore, proximal occlusion or trapping of the affected VA should be considered.4 Some authors have already reported surgical treatment of the patients with bilateral VADAs presenting with SAH.5-8 However, occlusion of the affected VA may increase the blood flow in the contralateral VA, resulting in increased hemodynamic shear stress on the VA wall.

View all citing articles on Scopus
View full text