Bilateral Vertebral Artery Dissecting Aneurysms Presenting with Subarachnoid Hemorrhage Treated by Staged Coil Trapping and Covered Stents Graft

Abstract

The treatment of bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid hemorrhage (SAH) is still challenging. The authors report a rare case of bilateral VADA treated with coil trapping of ruptured VADA and covered stents implantation after multiple unsuccessful stent assisted coiling of the contralateral unruptured VADA. A 44-year-old woman was admitted to our hospital because of severe headache and sudden stuporous consciousness. Brain CT showed thick SAH and intraventricular hemorrhage. Cerebral angiography demonstrated bilateral VADA. Based on the SAH pattern and aneurysm configurations, the right VADA was considered ruptured. This was trapped with endovascular coils without difficulty. One month later, the contralateral unruptured VADA was protected using a stent-within-a-stent technique, but marked enlargement of the left VADA was detected by 8-months follow-up angiography. Subsequently two times coil packing for pseudosacs resulted in near complete occlusion of left VADA. However, it continued to grow. Covered stents graft below the posterior inferior cerebellar artery (PICA) origin and a coronary stent implantation across the origin of the PICA resulted in near complete obliteration of the VADA. Covered stent graft can be used as a last therapeutic option for the management of VADA, which requires absolute preservation of VA flow.

Are Blood Blister-Like Aneurysms a Specific Type of Dissection? A Comparative Study of Blood Blister-Like Aneurysms and Ruptured Mizutani Type 4 Vertebral Artery Dissections

“…Nevertheless, it is not easy to correlate the natural history of a BBA with that of an arterial dissection arising in other parts of the vasculature in the clinical setting. This is mainly because the clinical features (shape, location, clinical presentation, and prognosis) of arterial dissections are more variable than those of BBAs which are strikingly homogeneous 3 , 5 , 17 , 21 , 24) . However, intracranial ruptured arterial dissections have surprisingly similar clinical characteristics in terms of appearance, fragility, and instability to those of BBAs 2 , 7 , 13 , 17 , 21 , 24) .…”

“…BBAs and VADs appear to have unique characteristics for their anatomic location, as both of them are rarely seen at arterial bifurcations. In addition to the dynamic nature of VADs, which include morphological changes on serial angiographic follow up (e.g., recanalization or pseudoaneurysm formation) 2 , 7 , 13 , 24) , incomplete treatment of a ruptured VAD usually results in dramatic aneurysmal growth or rupture 2 , 7 , 17 , 24) , and all of this represents their instability.…”

The Difference of Each Angiographic Finding After Multiple Stent According to Stent Type in Bilateral Vertebral Artery Dissection

“…In some cases, successful treatment with staged bilateral VA occlusion or staged coil trapping and covered stent grafts has been reported 3)14)20). However, staged treatment techniques do not apply in all cases, and the patient must be able to tolerate balloon test occlusion.…”

“…However, its large porosity might be insufficient for induction of intra-aneurysmal hemodynamic changes for thrombus formation. In addition, SESs have enough radial force to prevent stent migration, however, radial force may be insufficient for occlusion of the inlet or outlet of the dissecting aneurysm 20). Therefore, slow and careful balloon inflations with BMSs for prevention of iatrogenic dissection rupture may be more effective in VADs as compared with SES because balloon infarctions support more dissected wall apposition.…”

Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10-year neurointerventional experience

“…[2][3][4] Bilateral IVADAs account for less than 10% of all IVADAs, but their management is more complex and challenging. [5][6][7][8][9] Endovascular treatment has emerged as a major therapeutic option for IVADAs, with successful results reported for staged bilateral vertebral artery (VA) occlusion of bilateral IVADAs; 10 however, bilateral VA occlusion is not tolerated in many patients. Unilateral trapping or bilateral parent artery reconstructive therapy has been used to treat such intolerant patients.…”