- Department of Neurosurgery, Yokohama City University, Yokohama, Japan.
Correspondence Address:
Yu Masuko, Department of Neurosurgery, Yokohama City University, Yokohama, Japan.
DOI:10.25259/SNI_19_2022
Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Yu Masuko, Nobuyuki Shimizu, Ryosuke Suzuki, Jun Suenaga, Kagemichi Nagao, Fukutaro Ohgaki, Tetsuya Yamamoto. Reconstructive embolization for contralateral vertebral artery dissecting aneurysm that developed after internal trapping of ruptured vertebral artery dissection: A case report and literature review. 31-Mar-2022;13:124
How to cite this URL: Yu Masuko, Nobuyuki Shimizu, Ryosuke Suzuki, Jun Suenaga, Kagemichi Nagao, Fukutaro Ohgaki, Tetsuya Yamamoto. Reconstructive embolization for contralateral vertebral artery dissecting aneurysm that developed after internal trapping of ruptured vertebral artery dissection: A case report and literature review. 31-Mar-2022;13:124. Available from: https://surgicalneurologyint.com/surgicalint-articles/11495/
Abstract
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.
Keywords: Parent artery occlusion, Stent-assisted coiling, Subarachnoid hemorrhage, Vertebral artery dissection
INTRODUCTION
Intracranial vertebral artery dissection (VAD) or vertebral artery dissecting aneurysm (VADA) is occasionally discovered bilateral sides simultaneously.[
CASE REPORT
A 61-year-old man developed a sudden-onset headache and subsequent disturbance of consciousness while at work. On admission to a nearby hospital, his Glasgow Coma Scale score was 9 (E2V2M5), although pupil size and light reflexes were bilaterally intact. His medical history included hypertension, diabetes (HbA1c 6.5%), and Stanford Type B aortic dissection (treated conservatively), but he had currently no symptom. There was no family history of subarachnoid hemorrhage (SAH). Head computed tomography (CT) showed a diffuse and symmetrical SAH distributed mainly in the posterior cranial fossa [
Figure 1:
(a) Plain CT shows diffuse subarachnoid hemorrhage, mainly in the prepontine cistern. (b) 3DCTA shows dissecting aneurysm in the left intracranial VA (arrow) and poor depiction of the right VA. (c) Three-dimensional DSA shows wall irregularity and aneurysm formation of the left intracranial VA. (d) The right VAG showed a pearl and string sign on his right VA proximally to PICA origin suggesting dissection. (e) The left internal carotid angiography describes basilar artery and right AICA through posterior communicating artery. (f) The right vertebral angiography shows that the left PICA is patency after parent artery occlusion (arrowhead).
On POD 10, follow-up magnetic resonance angiography and time-of-flight imaging demonstrated patency of the right vertebral artery and the double-lumen sign, although the right vertebral artery diameter was not increased [
Figure 2:
(a) MRA after PAO shows patency of basilar artery. (b) TOF imaging after PAO demonstrated patency of the right VA and double-lumen sign suggesting dissection, though there was no expanded diameter suggesting aneurysm formation of the right VA. (c and d) The right vertebral angiography POD16 shows that left PICA patency and right VADA progressing revealed.
Figure 4:
(a) Angiography shows that LVIS blue stent is deployed after wraps coil incompletely. (b) Angiography shows that the balloon in stent is inflated and the coil is embolized. (c) The right VA angiography after stent-assisted coil embolization shows patency of the right VA and BA. (d) MRI shows no DWI high-intensity area.
Ethical approval for this study was granted by the Yokohama City University Human Ethics Committee (B191200034) in accordance with the research guidelines. The patient provided written informed consent for publication and use of the data in this report.
DISCUSSION
We report the case of a patient with the progression of an existing wall irregularity of the contralateral vertebral artery shortly after the surgical occlusion of a ruptured VADA. To the best of our knowledge, only 17 other cases of progressing or de novo contralateral vertebral artery wall irregularity in patients with initial unilateral VAD or VADA have been reported [
There are several treatment options for ruptured VAD or VADA. Reconstructive treatment is possible with two methods: stent-assisted coil embolization and flow diversion with multiple stents or flow diverter. In contrast, deconstructive treatment can be performed with endovascular PAO or surgical trapping, with or without the bypass technique. The appropriate treatment strategy must be chosen depending on individual factors,[
The hemodynamic stress after ipsilateral VA occlusion is a potential cause of contralateral VAD or VADA.[
Based on our review, contralateral VADs were diagnosed due to symptomatic ischemic or bleeding events in 10 of 18 cases (55.6%), and five of these patients subsequently died or remained severely disabled [
In this case, the right VADA progressed rapidly after PAO for the left VADA, and prevention of rupture by reconstructive immediately complete embolization was necessary. We adopted a stent-assisted coil embolization with balloon-instent technique (BIST) for the secondary treatment. This technique has several advantages.[
The small sample size of this review is a limitation. We studied 18 cases, including the present case. Large-scale studies are needed to elucidate further the pathophysiology of contralateral VAD developing after the occlusion of a primary VAD.
CONCLUSION
We were able to successfully treat a case of contralateral vertebral artery dissecting aneurysm that developed after internal trapping of ruptured vertebral artery dissection. Imaging reinspection of vascular morphology within 7-14 days after treatment of unilateral VAD may allow early detection and prophylactic treatment of newly developed contralateral VADs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We gratefully acknowledge the work of the past and present members of our department.
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