Treatment of a Ruptured Vertebrobasilar Fusiform Aneurysm Using Pipeline Embolization Device
A 73-year-old man presented with Hunt and Hess II SAH. There was no radiographic or clinical evidence of hydrocephalus on admission. He was on aspirin 325 mg and clopidogrel 75 mg daily for his coronary artery stent placed seven days earlier. Computed tomography (CT) angiography of the brain showed severely ectatic left vertebral and basilar arteries consistent with VFA. The right vertebral artery appeared irregular and non-dominant ().\nAfter careful evaluation, endovascular approach was deemed to be the most appropriate treatment. The patient was taken to neurointerventional suite and placed under general anesthesia. A complete 6-vessel cerebral angiogram demonstrated severe dolichoectasia involving the left vertebral and the basilar arteries. It also revealed a 2-mm blister in the right vertebral artery proximal to right PICA take off that was not apparent on pre-operative CT angiogram. Since either the left dolichoectatic vertebrobasilar artery or the right vertebral artery blister aneurysm could be the source of SAH, the decision was made to treat both.\nThrough a 6 French sheath, a 6F neuron guide catheter (Penumbra, CA) was used to catheterize the left vertebral artery. The patient was given 3,000 units of heparin intravenous injection with an activated clotting time of 214. His aspirin reaction units was 407; clopidogrel activity test showed 73% platelet inhibition with P2Y12 reactivity unit of 98. A Marksman catheter (Covidien, CA) along with a Synchro 2 (Stryker, MI) standard microwire was navigated through the left dolichoectatic vertebral artery into the basilar artery. Next, five PEDs (four 4.5 × 20 mm, one 4.5 × 18 mm) were deployed in a telescoping fashion starting from proximal part of the basilar artery down to the left vertebral artery, essentially reconstructing the entire length of the affected vertebrobasilar system. Each PED was placed within the previous one with 50% overlap. A cerebral angiogram after the PED placement demonstrated good patency of the target vessels and there was stasis in the irregularity outside the PED. Next, the right vertebral artery was selectively catheterized and one additional PED (3.0 × 16 mm) was placed across the blister in the right vertebral artery. The final angiogram from the left vertebral artery demonstrated patency of both vertebral arteries (). No technical complication occurred during the case. The patient was continued on aspirin 325 mg and clopidogrel 75 mg daily.\nCT angiogram on postoperative day 5 showed patency of the stents (). MRI at three months after the procedure showed no ischemic changes suggesting patency of perforators in the vertebrobasilar system. Conventional cerebral angiogram at six months demonstrated successful reconstruction of the vertebrobasilar system and thrombosis of the VFA (). The patient remained neurologically well and was living independently at home.