Endovascular Coil Trapping of a Ruptured Dissecting Aneurysm of the Vertebral Artery Using Detachable Coils and Micro-Tornado® Coils
An 80-year-old male was transferred to our emergency room, with mental deterioration after posterior neck pain and sudden severe headache (Hunt and Hess grade IV). Computed tomography (CT) of the brain showed SAH and intraventricular hemorrhages that were more predominant in cisterns around the medulla and pons than in the basal cistern (Fisher grade IV) (). CT angiography showed a dissecting aneurysm arising from the left VA. A CT source image also showed a pseudoaneurysm and intimal flap, diagnosed with a VADA ().\nA vertebral angiogram showed a left VADA measuring 5 × 8 mm in size, which showed irregular narrowing and a dilated portion. The left posterior inferior cerebellar artery (PICA) was visualized at the distal portion of the dissected segment of the left VA (). Endovascular coil trapping of the dissected segment was performed just after diagnostic angiography using six GDCs and two MTCs ().\nIn this case, the sheath was placed in the right femoral artery. A 6 Fr Envoy catheter (Cordis Endovascular Systems, Bridgewater, NJ) was placed in the left subclavian artery near the origin portion of the VA. After placement of the guiding catheter, the patient received a bolus injection of heparin (2000 U) and control-activated clotting times were determined hourly. We planned VA occlusion by trapping on both sides of the lesion, using the double microcatheter technique. First, an Excelsior™ SL-10 microcatheter (Boston Scientific Corp, Natick, MA) was manipulated with the tip curved 45° and advanced into the distal left VA using a Synchro®-14 neuro guidewire (Stryker Neurovascular, Kalamazoo, MI). The microcatheter was advanced slowly into the lesion up to the distal end of the dissected segment of the aneurysm. The attempt to advance the other microcatheter into the proximal end of the DA failed because the stenotic lesion of the proximal portion of the DA was too small to pass to the other microcatheter. The right VA origin portion was severely tortuous; thus, we failed to apply the double microcatheter technique. Instead, a Rebar™-18 microcatheter (ev3 Endovascular, Plymouth, MN) was advanced into the proximal portion of the stenotic lesion using a microguidewire. Multiple GDCs, totaling 42 cm in length, were placed at the dilated segment and two MTCs (Tornado® Embolization Microcoil™, Cook incorporated, Bloomington, IN, proximal end diameter 3 mm × distal end diameter 2 mm) were then deployed (). The size of MTCs was selected to match the diameter of the trapped segment. Before detachment of the GDCs, repeat angiography was performed in order to check coil placement at the affected site. After deployment of the MTCs, postoperative angiography showed complete occlusion of the dissecting aneurysm, while the left PICA was sacrificed. The patient was transported to the neurological intensive care unit with no occurrence of remarkable events. An magnetic resonance (MR) angiography performed one day after the procedure showed complete occlusion of the left VADA with appropriate flow to the basilar artery via the right VA and no regrowth or residual portion of the aneurysm ().\nFortunately, the patient regained consciousness. A follow-up MR image showed embolic ischemic lesions in the left cerebellum (), however, no neurological deficit was detected and no re-bleeding from the aneurysm was observed.