J Cerebrovasc Endovasc Neurosurg.  2023 Mar;25(1):69-74. 10.7461/jcen.2022.E2022.03.002.

Treatment for subarachnoid hemorrhage due to ruptured posterior cerebral arterial dolichoectasia with aortic arch anomaly

• Yun YI
• Chang CH
• Kim JH
• Jung YJ

• KMID: 2540809
• DOI: http://doi.org/10.7461/jcen.2022.E2022.03.002

Abstract

Subarachnoid hemorrhage (SAH) due to ruptured posterior cerebral artery (PCA) intracranial arterial dolichoectasia (IADE) is very rare. As these lesions are difficult to treat microsurgically, neurointervention is preferred because the dolichoectatic artery does not have a clear neck, and the surgical field of view was deep seated with the SAH. However, in some cases, neurointervention is difficult due to anatomical variation of the blood vessel to access the lesion. In this case, a 30-year-old male patient presented with a ruptured PCA IADE and an aortic arch anomaly. Aortic arch anomalies render it difficult to reach the ruptured PCA IADE via endovascular treatment. The orifice of the vertebral artery (VA) was different from the usual cases, so it was difficult to find the entrance. After only finding the VA and arriving at the lesion along the VA, trapping was performed. Herein, we report the PCA IADE with aortic arch anomaly endovascular treatment methods and results.

Keyword

Aortic arch anomaly; Intracranial arterial dolichoectasia; Posterior cerebral artery; Subarachnoid hemorrhage

Figure

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  Fig. 1. Brain multi-phased computed tomography angiography is showing subarachnoid hemorrhage in basal on left crural cistern and left ambient cistern (A). Three-dimensional reconstructed angiography showed left P2 segment were elongated and enlarged (arrow) (B).

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  Fig. 2. In anteroposterior view of aortogram, the left subclavian artery was identified, but the left vertebral artery (VA) was not seen and the shape of the aortic arch was unusual (A). Aortic arch three-dimensional image, left subclavian artery comes off posteriorly from the descending aorta at the level of T4. Arrow: left subclavian artery (B). From the left subclavian artery orifice to the left subclavian artery at the level of T1, it is pointing to the right. After passing the left first rib, it turns to the left. Left VA comes off superiorly from the left subclavian artery at the level of T2. Arrow: left subclavian artery, Arrowhead: left VA (C). From the aortic arch to the ascending aorta, it is clockwise. Two aortic arch aneurysm is found (D).

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  Fig. 3. Left vertebral artery angiogram, working view showing a tortuous and elongated Lt. P2 (A, B). After first, second coil was inserted (C). Followed angiogram, there were no distal flow left posterior cerebral artery after the coil embolization (D). Followed stroke magnetic resonance imaging (MRI), there were focal acute infarction on left lateral thalamus (E).

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