Subsequent Subarachnoid Hemorrhage from Clinically Unrelated Vertebral Artery Dissection after Thrombolytic Therapy

Abstract

Thrombolysis administration poses certain safety issues in ischemic stroke patients with cerebrovascular changes that are vulnerable to hemorrhage. Furthermore, the lack of related studies has resulted in an unclear understanding of thrombolysis safety in ischemic stroke patients with intracranial dissection, including those involving the vertebral artery. This study describes a case of a 59-year-old female who developed subarachnoid hemorrhage from clinically unrelated vertebral artery dissection after thrombolysis. Histories of severe headache with posterior fossa involvement in patients receiving thrombolytic therapy may indicate careful assessment for intracranial vertebral artery dissection, even if the clinical picture of the patient suggests another arterial syndrome.

Keywords: Subarachnoid hemorrhage; Thrombolytic therapy; Vertebral artery dissection.

Fig. 1.

A case of subarachnoid hemorrhage caused by the dissection of the left vertebral artery after thrombolytic therapy. (A) Initial brain computed tomography (CT) scan of a 59-year-old female patient shows no intracranial hemorrhage. (B) Diffusion-weighted magnetic resonance image and perfusion CT scan show significant mismatch on the left temporal lobe. (C) Initial CT angiography reveals mild dilation (arrow) and proximal narrowing (arrowhead) in the V4 segment of the left vertebral artery and a small non-ruptured aneurysm in the bifurcation of the left middle cerebral artery. (D) Repeated CT scans reveal a massive subarachnoid hemorrhage. (E) Repeated CT angiograms show more prominent dilation and narrowing in the V4 segment of the left vertebral artery than findings in (C). (F) Intraoperative findings reveal a dissecting aneurysm with clots of this vertebral artery (arrow).