Subarachnoid Hemorrhage from Vertebrobasilar Dissecting Aneurysm Treated with Staged Bilateral Vertebral Artery Occlusion: The Importance of Early Follow-up Angiography: Technical Case Report

Subarachnoid Hemorrhage from Vertebrobasilar Dissecting Aneurysm Treated with Staged Bilateral... AbstractOBJECTIVE AND IMPORTANCE:Vertebrobasilar dissecting aneurysms are an uncommon but increasingly recognized cause of subarachnoid hemorrhage (SAH). We describe a patient with SAH caused by a dissecting aneurysm involving both vertebral arteries as well as the basilar trunk. The patient was treated successfully with proximal occlusion of the vertebral arteries using endovascular balloon occlusion in two stages. The importance of early follow-up angiography to document progression or resolution of untreated dissections is emphasized. This approach is suggested as definitive treatment for vertebrobasilar dissection in appropriate circumstancesCLINICAL PRESENTATION:A 41-year-old man presented with SAH from spontaneous vertebrobasilar dissection. Angiography revealed aneurysmal dilation of the right vertebral artery and basilar trunk and occlusion of the left vertebral artery.INTERVENTION:The dissecting aneurysm was treated with balloon occlusion of the right vertebral artery. Repeat angiography 2 weeks later demonstrated resolution of the left vertebral occlusion, with restoration of antegrade flow in the basilar trunk and increased filling of the right vertebral and basilar dissecting aneurysms. Balloon occlusion of the left vertebral artery led to aneurysm thrombosis and excellent clinical outcome.CONCLUSION:Bilateral vertebrobasilar dissecting aneurysms are an uncommon cause of SAH. If unilateral proximal vertebral artery occlusion is chosen as the initial treatment, it is essential to document the status of the contralateral vessel using follow-up angiography. Staged bilateral vertebral artery occlusion should be considered in the event of recurrent or progressive aneurysm enlargement. Endovascular balloon occlusion has advantages over proximal clipping of the parent vessel: cranial nerve manipulation is avoided, test occlusion in the awake patient can be performed at the site of permanent occlusion, and therapeutic levels of anticoagulation can be maintained throughout and after the procedure, thus diminishing the likelihood of thromboembolic complications. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Subarachnoid Hemorrhage from Vertebrobasilar Dissecting Aneurysm Treated with Staged Bilateral Vertebral Artery Occlusion: The Importance of Early Follow-up Angiography: Technical Case Report

Subarachnoid Hemorrhage from Vertebrobasilar Dissecting Aneurysm Treated with Staged Bilateral Vertebral Artery Occlusion: The Importance of Early Follow-up Angiography: Technical Case Report

1 2 5 8 Redekop et al. S pontaneous arterial dissection involv­ Subarachnoid Hemorrhage from ing the vertebrobasilar circulation is ar uncom m on but increasingly recognized Vertebrobasilar Dissecting Aneurysm condition. Intracranial dissection of th e vertebral artery m ay occur with brain­ Treated with Staged Bilateral Vertebral stem infarction, subarachnoid hemor­ rhage (SAH), or mass effect caused b y Artery O cclusion: The Importance of compression of the brainstem or low er cranial nerves (6 ). These lesions are asso­ Early Follow-up Angiography: Technical ciated with significant rates of morbidih and mortality (1, 2, 4, 7, 8 , 13, 15,25), Case Report Dissecting aneurysms of the basilar artery are identified less frequently than their vertebral artery counterparts, but they ex­ hibit similar clinical features and out­ G a r y R e d e k o p , M . D . , K a r e l T e r B r u g g e , M . D . , comes (4, 5, 10, 14, 17, 21). R o b e r t W i l l i n s k y , M . D . Lacking definitive necks suitable for Department of Surgery, Division of Neurosurgery (GR), University of British Columbia, clipping, vertebral dissecting aneurysms Vancouver, and Department of Medical Imaging, Division of Neuroradiology (KTB, RW), presenting with SAH have usually been University of Toronto, Toronto, Canada treated with proximal vessel occlusion or trapping, using direct microsurgical or endovascular techniques (3,8,9,11,13,15, 20, 23). This approach leads to reversal or OBJECTIVE AND IM PORTANCE: Vertebrobasilar dissecting aneurysms are an un­ elimination of flow in the region of dissec­ common but increasingly recognized cause of subarachnoid hemorrhage (SAH). tion, preventing further expansion and ul­ W e describe a patient with SAH caused by a dissecting aneurysm involving both timately promoting aneurysm thrombo­ vertebral arteries as well as the basilar trunk. The patient was treated successfully sis. In this situation, the posterior with...
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Publisher
Congress of Neurological Surgeons
Copyright
© Published by Oxford University Press.
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1097/00006123-199911000-00056
Publisher site
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Abstract

AbstractOBJECTIVE AND IMPORTANCE:Vertebrobasilar dissecting aneurysms are an uncommon but increasingly recognized cause of subarachnoid hemorrhage (SAH). We describe a patient with SAH caused by a dissecting aneurysm involving both vertebral arteries as well as the basilar trunk. The patient was treated successfully with proximal occlusion of the vertebral arteries using endovascular balloon occlusion in two stages. The importance of early follow-up angiography to document progression or resolution of untreated dissections is emphasized. This approach is suggested as definitive treatment for vertebrobasilar dissection in appropriate circumstancesCLINICAL PRESENTATION:A 41-year-old man presented with SAH from spontaneous vertebrobasilar dissection. Angiography revealed aneurysmal dilation of the right vertebral artery and basilar trunk and occlusion of the left vertebral artery.INTERVENTION:The dissecting aneurysm was treated with balloon occlusion of the right vertebral artery. Repeat angiography 2 weeks later demonstrated resolution of the left vertebral occlusion, with restoration of antegrade flow in the basilar trunk and increased filling of the right vertebral and basilar dissecting aneurysms. Balloon occlusion of the left vertebral artery led to aneurysm thrombosis and excellent clinical outcome.CONCLUSION:Bilateral vertebrobasilar dissecting aneurysms are an uncommon cause of SAH. If unilateral proximal vertebral artery occlusion is chosen as the initial treatment, it is essential to document the status of the contralateral vessel using follow-up angiography. Staged bilateral vertebral artery occlusion should be considered in the event of recurrent or progressive aneurysm enlargement. Endovascular balloon occlusion has advantages over proximal clipping of the parent vessel: cranial nerve manipulation is avoided, test occlusion in the awake patient can be performed at the site of permanent occlusion, and therapeutic levels of anticoagulation can be maintained throughout and after the procedure, thus diminishing the likelihood of thromboembolic complications.

Journal

NeurosurgeryOxford University Press

Published: Nov 1, 1999

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