- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, 132 Katsura-cho, Sakae-ku, Yokohama 247-8581, Japan
Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, 132 Katsura-cho, Sakae-ku, Yokohama 247-8581, Japan
DOI:10.4103/2152-7806.131187Copyright: © 2014 Tamase A This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Tamase A, Kamide T, Mori K, Kitamura Y, Shima H, Seki S, Nomura M. Cerebellar hemorrhage after embolization of ruptured vertebral dissecting aneurysm proximal to PICA including parent artery. Surg Neurol Int 21-Apr-2014;5:59
How to cite this URL: Tamase A, Kamide T, Mori K, Kitamura Y, Shima H, Seki S, Nomura M. Cerebellar hemorrhage after embolization of ruptured vertebral dissecting aneurysm proximal to PICA including parent artery. Surg Neurol Int 21-Apr-2014;5:59. Available from: http://sni.wpengine.com/surgicalint_articles/cerebellar-hemorrhage-after-embolization-of-ruptured-vertebral-dissecting-aneurysm-proximal-to-pica-including-parent-artery/
Background:Some complications related to vertebral artery occlusion by endovascular technique have been reported. However, cerebellar hemorrhage after vertebral artery occlusion in subacute phase is rare. In this report, we describe a patient who showed cerebellar hemorrhage during hypertensive therapy for vasospasm after embolization of a vertebral dissecting aneurysm.
Case Description:A 56-year-old female with a ruptured vertebral dissecting aneurysm proximal to the posterior inferior cerebellar artery developed cerebellar hemorrhage 15 days after embolization of the vertebral artery, including the dissected site. In this patient, the preserved posterior inferior cerebellar artery fed by retrograde blood flow might have been hemodynamically stressed during hypertensive and antiplatelet therapies for subarachnoid hemorrhage, resulting in cerebellar hemorrhage.
Conclusion:Although cerebellar hemorrhage is not prone to occur in the nonacute stage of embolization of the vertebral artery, it should be taken into consideration that cerebellar hemorrhage may occur during hypertensive treatment.
Keywords: Cerebellar hemorrhage, dissecting aneurysm, embolization, posterior inferior cerebellar artery, vertebral artery
Dissecting aneurysms of the vertebral artery (VA) cause subarachnoid hemorrhage (SAH) or ischemia. For the treatment of a ruptured dissecting aneurysm of VA, several options have been reported.[
A 56-year-old female suffered a sudden onset of consciousness disturbance. She was brought to our hospital by ambulance. Computed tomography (CT) demonstrated SAH and ventricular enlargement [
(a) Angiogram showing a dissecting aneurysm (arrow) in the right VA proximal to PICA (arrowheads). (b) Postoperative right VAG demonstrating complete occlusion of the aneurysm and VA. (c) Left VAG showing opacification of the distal right VA and right PICA via blood flow through the VA union
Endovascular embolization of the dissecting aneurysm was performed under local anesthesia. A guiding catheter with balloon was advanced to the right VA. A microcatheter (Excelcior SL-10, Stryker, MI, USA) was advanced to the right VA on the distal side of the aneurysm with the aid of microguide-wire (Transend EX, Stryker) via the guiding catheter. The balloon of the guiding catheter was inflated for flow control of VA. A Guglielmi detachable coil (4 mm × 8 cm) was initially placed in the aneurysm and right VA proximal to PICA. Then, the aneurysm cavity was embolized roughly with larger coils. After partial embolization of the ruptured portion of VA, the micro-catheter was pulled and placed in the proximal VA, and the VA was tightly embolized. The dissecting aneurysm and VA were embolized with a total of 12 platinum coils. A postoperative angiogram [
Postoperatively, to prevent thrombosis, intravenous administration of heparin was begun after embolization and continued for 7 days. She was treated with fasudil hydrochloride hydrate (90 mg/day) for vasospasm, and was kept in a hypertensive state. Her systolic blood pressure was kept higher than 140 mmHg. The intravenous administration of 80 mg of sodium ozagrel was performed to prevent vasospasm and thrombosis. These treatments for vasospasm and thrombosis was started 2 days after the VA occlusion. Fifteen days after embolization, the patient vomited. CT demonstrated right cerebellar hemorrhage [
The goal of treatment for a ruptured dissecting aneurysm is the isolation of the lesion from the blood circulation to prevent rerupture.[
In patients with VA dissecting aneurysms who underwent VA occlusion, major perioperative complications were rebleeding from the aneurysm and ischemia.[
In the present case, PICA originated distal to the embolization site. PICA was fed by retrograde blood flow from the contralateral VA after embolization of the aneurysm. Hemodynamic stress on PICA fed via VA union might not be so high. Commonly, hemodynamic stress such as hyperperfusion improves within a week.[
Even in a case such as ours, a rare complication such as cerebellar hemorrhage should be taken into consideration during the postoperative period. Although induced hypertension and antiplatelet therapy are effective for preventing vasospasm after SAH, careful control of the blood pressure is essential in acute and subacute stages after VA occlusion.
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