J Cerebrovasc Endovasc Neurosurg.  2013 Mar;15(1):30-33. 10.7461/jcen.2013.15.1.30.

Treatment of a Ruptured Vertebrobasilar Fusiform Aneurysm Using Pipeline Embolization Device

• Tan LA
• Moftakhar
• Lopes DK

• KMID: 2172028
• DOI: http://doi.org/10.7461/jcen.2013.15.1.30

Abstract

Treatment options of ruptured vertebrobasilar fusiform aneurysms (VFA) are limited and often carry significant mortality and morbidity. We report the use of Pipeline Embolization Device (PED) to successfully treat a patient with a ruptured vertebrobasilar fusiform aneurysm (VFA) who presented with subarachnoid hemorrhage (SAH). A 73 year-old man with a history of cardiac stent placement seven days earlier presented with Hunt-Hess II SAH. He was taking aspirin and clopidogrel. Computed tomography angiogram revealed a large vertebrobasilar fusiform aneurysm. Microsurgical treatment options are technically challenging and carry high risk. He underwent endovascular treatment of the ruptured VFA using overlapping PEDs. Five PEDs were placed in a telescoping fashion to reconstruct the affected portions of the left vertebral and basilar arteries. An additional 2-mm blister aneurysm in the right vertebral artery was also discovered during the conventional cerebral angiography and was treated with one additional PED. The patient remained neurologically intact after the procedure. He was continued on aspirin and clopidogrel. Follow-up magnetic resonance imaging at three months demonstrated patency of the stents without any evidence of ischemic change. Follow-up conventional cerebral angiogram at six months demonstrated thrombosis of the VFA and reconstruction of the vertebrobasilar system. The patient remained clinically well. An endovascular approach using PEDs can be a safe and effective treatment option for ruptured VFA in selected cases.

Keyword

Fusiform aneurysm; Ruptured aneurysm; Subarachnoid hemorrhage; Therapeutic embolization; Vertebrobasilar dolichoectasia

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Aspirin
Basilar Artery
Blister
Cerebral Angiography
Embolization, Therapeutic
Follow-Up Studies
Humans
Magnetic Resonance Imaging
Stents
Subarachnoid Hemorrhage
Thrombosis
Ticlopidine
Vertebral Artery
Vertebrobasilar Insufficiency
Aspirin
Ticlopidine

Figure

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  Fig. 1 Computed tomography (CT) of the brain without contrast (left) showing subarachnoid hemorrhage in the prepontine, ambient and crural cisterns; CT angiogram of the brain (right) showing a vertebrobasilar fusiform aneurysm, also known as vertebrobasilar dolichoectasia involving the left vertebral and basilar arteries. The right vertebral artery is irregular and non-dominant.

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  Fig. 2 Pretreatment conventional cerebral angiogram (left) demonstrating fusiform dilation of the left vertebral and basilar arteries, along with a 2 mm blister aneurysm (arrow) in the right vertebral artery proximal to posterior inferior cerebellar artery takeoff; post-treatment angiogram (right) demonstrating reconstruction of affected vessel lumen and stasis of blood flow in the irregular portion of the vessels outside of Pipeline Embolization Device construct.

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  Fig. 3 Comparison of pretreatment CT angiogram (left) and CT angiogram on post operative day five (right), demonstrating patent vertebrobasilar system and reconstruction of the fusiform vertebrobasilar artery after treatment.

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  Fig. 4 Cerebral angiogram immediately after Pipeline embolization device placement (left); Follow-up cerebral angiogram at six-month after procedure (right) showing remodeling of left vertebral and basilar arteries and thrombosis of the vertebrobasilar fusiform aneurysm.

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