Treatment Challenges of a Primary Vertebral Artery Aneurysm Causing Recurrent Ischemic Strokes

Abstract

Background. Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; surgical and endovascular therapy options are debated and long-term complication may occur. Case Report. A 53-year-old man affected by neurofibromatosis type 1 (NF1) came to our attention for recurrent vertebrobasilar embolic strokes, caused by a primary giant, partially thrombosed, fusiform aneurysm of the left extracranial vertebral artery. The aneurysm was treated by endovascular approach through deposition of Guglielmi Detachable Coils in the proximal segment of the left vertebral artery. Six years later the patient presented stroke recurrence. Cerebral angiography and Color Doppler Ultrasound well characterized the unique hemodynamic condition developed over the years responsible for the new embolic event: the aneurysm had been revascularized from its distal portion by reverse blood flow coming from the patent vertebrobasilar axis. A biphasic Doppler signal in the left vertebral artery revealed a peculiar behavior of the blood flow, alternately directed to the aneurysm and backwards to the basilar artery. Surgical ligation of the distal left vertebral artery and excision of the aneurysm were thus performed. Conclusion. This is the first described case of NF1-associated extracranial vertebral artery aneurysm presenting with recurrent embolic stroke. Complete exclusion of the aneurysm from the blood circulation is advisable to achieve full resolution of the embolic source.

Successful Endovascular Trapping for Symptomatic Thrombosed Giant Unruptured Aneurysms of the V1 and V2 Segments of the Vertebral Artery: Case Report and Literature Review

“…Strambo et al reported that proximal occlusion was implemented for vertebrobasilar embolic strokes caused by a primary, partially thrombosed, giant fusiform aneurysm of the left extracranial VA, but six years later, the result was stroke recurrence because the aneurysm had been revascularized from its distal portion by reverse blood flow coming from the patent vertebrobasilar axis. 31) Furthermore, following treatment with proximal occlusion with a detachable balloon, a vertebral arteriovenous fistula developed in the same region 11 years later. 17) These might be therapeutic pitfalls of proximal occlusion.…”

Extracranial Vertebral Artery-Internal Jugular Vein-Spinal Vein Fistula in Neurofibromatosis Type I: Case Report and Literature Review

“…and interventional embolization (balloons, coils, tissue glue, vinyl alcohol polymers, etc.) (25)(26)(27)(28)(29)(30). However, whether it is traditional open surgery or interventional embolization, vascular fragility associated with NF-1 brings great risk to treatment, viz., rupture of blood vessels and bleeding.…”

Successful endovascular coil embolisation of a ruptured V1-segment vertebral artery dissecting aneurysm making a fistula with the adjacent vein

“…CT angiography and DSA are the standard tools to diagnose and reveal the anatomy of vasculature and to plan treatment. Treatment options include ligation, isolation, balloon embolisation, onyx embolisation and coil embolisation 6 9–11. There is no single standardised treatment option for V1-segment vertebral artery aneurysms with a fistula.…”

“…Both surgical and endovascular treatments carry potential risks and technical difficulties. The best treatment options are still controversial in such aneurysms 3–6. Here we present a case of a successfully treated ruptured dissecting V1 vertebral artery aneurysm making a fistula with the adjacent vein using endovascular coils and placement of a distal plug to close the fistula and proximally occlude the parent artery.…”