Subarachnoid hemorrhage due to ruptured vertebral artery dissecting aneurysm (rVADA) is associated with a high frequency of acute rebleeding and requires early treatment following onset. Parent artery occlusion (PAO) or stentassisted coiling (SAC) embolization is selected as a treatment option according to the individual patient condition. This report is a retrospective examination evaluating the treatment outcomes for rVADA. Methods: The subjects were 20 rVADA patients (16 men and 4 women) who underwent endovascular treatment at our institution. The mean patient age was 52.9 years. Ten patients each were allocated to the PAO group and SAC group. We evaluated and compared the following parameters: presence of hemorrhagic complications, presence of ischemic complications, requirement of retreatment, and Glasgow Outcome Scale (GOS) after 90 days. Results: The reasons for selecting SAC were contralateral occlusion or a small diameter in three patients, the posterior inferior cerebellar artery (PICA) involvement in three patients, perforating artery from dissected lesion in five patients, and anterior spinal artery in one patient. There was no rebleeding in any patient. Symptomatic ischemic complications were observed in four patients in the PAO group and in one in the SAC group. Hyper-intense lesions in the brainstem on MRI DWI were noted in five patients in PAO group and in one in the SAC group. Retreatment was required for three patients in the PAO group and for four in the SAC group. Favorable outcomes (GOS 4, 5) after 90 days were observed for three patients in the PAO group and for eight patients in the SAC group (p = 0.0257). Conclusion: SAC that can preserve branches is a useful treatment option for rVADA. Further studies on a greater number of subjects are required to establish the optimal dose of antiplatelet agents and anticoagulants, and for stent selection. Keywords▶ ruptured vertebral artery dissecting aneurysm, endovascular treatment, stent-assisted coil embolization, treatment results, preservation of branches This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

Advances in both critical care medicine and diagnostic imaging have allowed increased recognition of traumatic atlanto-occipital dislocation(AOD) . AOD is often overlooked due to severe coexistent complications, and even in cases with mild concomitant complications, AOD may be overlooked because of its anatomical specificity. Here we report a case of traumatic AOD in a 38-yearold woman. She had fallen from the 4th floor of a building and was unconscious on arrival at the hospital, with a Glasgow Coma Scale score of E1V1M1. In the emergency ward, a chest drain was inserted for left traumatic hemopneumothorax. After her vital signs had stabilized, clinical and radiological workups revealed traumatic AOD with subarachnoid hemorrhage at the craniocervical junction. Furthermore, multiple rib fractures, traumatic aortic dissection, T10 burst fracture, and dislocation of the temporomandibular joint were diagnosed. After intensive care treatment, the patient regained consciousness and could move her limbs fully except for the left deltoid muscle(manual muscle test, 4/5) . Fixation was performed for the ribs and thoracic burst fracture before occipital-C2 fusion. She was able to walk and manage all activities of daily living after 2 months of clinical treatment and rehabilitation. As emergency medicine and care continue to develop, survival after AOD will increase, meaning that immediate and appropriate diagnosis and treatment will be increasingly important. Traumatic subarachnoid hemorrhage at the craniocervical junction is often complicated by AOD. This is important to keep in mind for doctors who do not specialize in pathologies of the spinal cord.

Background: It is not well-known that contralateral vertebral artery dissecting aneurysms (VADA) may be newly revealed after parental artery occlusion for unilateral VADA. However, the optimal treatment strategies and perioperative management have not been established. In this report, we present the case of a patient who required reconstructive embolization in the subacute stage for contralateral VADA developed after endovascular internal trapping of the ruptured VADA. Case Description: A 61-year-old man developed subsequent disturbance of consciousness. Head CT showed a diffuse and symmetrical SAH. 3DCT revealed a fusiform aneurysm of the left intracranial vertebral artery with bleb formation. We performed emergency endovascular parent artery occlusion of the left vertebral artery. A digital subtraction angiography on postoperative day 16 showed continued occlusion of the left VA, and a fusiform aneurysm was noted at the right VA. We performed reconstructive embolization and the patient eventually recovered with minimal persistent symptoms. Conclusion: Since the outcomes of contralateral VAD complicated by infarction or hemorrhage are poor, and most cases develop within 7–14 days after endovascular internal trapping for unilateral VAD, performing bilateral radiographic reinspection within this time frame is recommended for early detection and preventive treatment of possible contralateral VADs.

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