Reconstructive embolization for contralateral vertebral artery dissecting aneurysm that developed after internal trapping of ruptured vertebral artery dissection: A case report and literature review.

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.

Treatment Outcomes of Stent-Assisted Coil Embolization for Ruptured Vertebral Artery Dissecting Aneurysms: The Preservation of Branches May Improve the Prognosis.

Objective: Subarachnoid hemorrhage due to ruptured vertebral artery dissecting aneurysm (rVADA) is associated with a high frequency of acute rebleeding and requires early treatment following onset. Parent artery occlusion (PAO) or stent-assisted coiling (SAC) embolization is selected as a treatment option according to the individual patient condition. This report is a retrospective examination evaluating the treatment outcomes for rVADA. Methods: The subjects were 20 rVADA patients (16 men and 4 women) who underwent endovascular treatment at our institution. The mean patient age was 52.9 years. Ten patients each were allocated to the PAO group and SAC group. We evaluated and compared the following parameters: presence of hemorrhagic complications, presence of ischemic complications, requirement of retreatment, and Glasgow Outcome Scale (GOS) after 90 days. Results: The reasons for selecting SAC were contralateral occlusion or a small diameter in three patients, the posterior inferior cerebellar artery (PICA) involvement in three patients, perforating artery from dissected lesion in five patients, and anterior spinal artery in one patient. There was no rebleeding in any patient. Symptomatic ischemic complications were observed in four patients in the PAO group and in one in the SAC group. Hyper-intense lesions in the brainstem on MRI DWI were noted in five patients in PAO group and in one in the SAC group. Retreatment was required for three patients in the PAO group and for four in the SAC group. Favorable outcomes (GOS 4, 5) after 90 days were observed for three patients in the PAO group and for eight patients in the SAC group (p = 0.0257). Conclusion: SAC that can preserve branches is a useful treatment option for rVADA. Further studies on a greater number of subjects are required to establish the optimal dose of antiplatelet agents and anticoagulants, and for stent selection.