Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature

Abstract

Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.

Keywords: Endovascular surgery; flow diversion; pseudoaneurysm; subarachnoid hemorrhage.

Figure 1

Noncontrast axial computed tomography of the head showing diffuse subarachnoid blood and hydrocephalus

Figure 2

Right vertebral artery digital subtraction angiography anteroposterior (a) and lateral (b) views demonstrating the V4 segment dissection and associated intracranial pseudoaneurysm (arrow). (b) The excrescence (arrow), denoting the point of rupture, is seen emanating from the intracranial pseudoaneurysm. (c) Magnified lateral view again showing dissection associated narrowing of vertebral artery proximal to posterior inferior cerebellar artery (double arrows), the large ruptured intracranial pseudoaneurysm (arrow), and a second smaller sack distal to the posterior inferior cerebellar artery origin

Figure 3

(a) Digital subtraction angiography lateral view demonstrating the jailed coiling microcatheter (arrow) and deployed pipeline embolization device (double arrows). (b) Immediate postcoiling run demonstrating obliteration of the intracranial pseudoaneurysm and preservation of the posterior inferior cerebellar artery and vertebral artery

Figure 4

Digital subtraction angiography anteroposterior (a and b) lateral views of the right vertebral artery 48 h postintervention. There is complete obliteration of the intracranial pseudoaneurysm and second small distal sack. (b) Minimal residual irregularity noted along the vertebral artery dissection (arrow)

Figure 5

Six-month digital subtraction angiography lateral (a and b) oblique views of the right vertebral artery showing patent vasculature (arrow), obliteration of the intracranial pseudoaneurysm (double arrows), and resolution of the dissection (arrowhead)