![]() There was no history of preceding trauma, tobacco use, or known connective tissue disorders. ILLUSTRATIVE CASEĪ 57-year-old man with a history of hypertension and mechanical valve replacement, on warfarin, presented to Harbor-UCLA Medical Center after experiencing severe headache and decreasing level of consciousness the precise time of onset was unknown. Treatment options and considerations for treatment of this condition were reviewed. The patient was ultimately treated with a flow-diverting stent. Here, we report an illustrative case of a patient with VADA involving the origin of PICA, with anatomically poor collateral flow to PICA demonstrated on angiography. However, the risks associated with these treatment options are not clearly understood in the context of VADA involving PICA, and there are other variables (e.g., arterial configuration, presence of collaterals, operator skill, and potential bleeding events from antiplatelet therapy following endovascular treatment) that may factor into favorable treatment outcomes. Many endovascular and surgical treatment options for VADA have been proposed, and new developments such as flow-diverting stents continue to expand the armamentarium. Involvement of branch vessels of the VA, for example, PICA, further complicates matters due to the need to preserve brainstem and cerebellar perfusion, limiting treatment options and resulting in worse outcomes. VADA is usually not amenable to treatment with standard clipping or coil embolization due to the morphology of the lesion. Therefore, ruptured VADA is treated emergently to prevent mortality and severe disability. In patients with rebleeding, the mortality rate is high and has been estimated near 50%. However, ruptured VADA presents a precarious situation with a high propensity for subsequent rebleeding, estimated at 30–70% and typically occurring within hours to days of the initial event. Due to its uncertain natural history, the management of unruptured lesions is controversial. Alongside surgical and endovascular treatment options, conservative management may be considered. Unruptured VADA may present with headache, ischemic symptoms (e.g., lateral medullary syndrome), or mass effect, and remain stable or even improve without treatment. The hematoma may be eccentric to the adventitia or intima subadventitial dissection preferentially occurs in the VA alone and presents as aneurysmal enlargement and SAH whereas subintimal dissection preferentially involves the basilar artery and presents with luminal narrowing and brainstem ischemia. Intracranial VADA results from a tear in the intima, degeneration of the media, or disruption of the internal elastic lamina, which lead to the formation of an intramural hematoma. ![]() Vertebral artery dissecting aneurysms (VADA) cause 3–5% of cases of subarachnoid hemorrhage (SAH), particularly in middle-aged men, and can occasionally involve the posterior inferior cerebellar artery (PICA). Keywords: Flow-diverting stent, Posterior inferior cerebellar artery, Vertebral artery dissecting aneurysm In select cases, in which the surgical risk is low or in which the anatomy is favorable (e.g., nondominant parent vessel or robust collateral circulation in the involved territories), parent artery trapping with or without microsurgical revascularization can be considered. Flow-diverting stents appear to offer the most favorable balance of securing the aneurysm and avoiding medullary infarction, but the risks and optimal anti-thrombotic treatment strategy are incompletely understood. The methods of surgical and endovascular treatment of these cases were reviewed, with particular focus on the rationale of treatment, outcomes, and complications.Ĭonclusion: Numerous treatment options for VADA involving PICA have been reported with different risk and benefit profiles. Review of the literature identified 124 cases of VADA involving the PICA origin described over the past decade. Ultimately, the patient experienced a contralateral intraparenchymal hemorrhage leading to death. After consideration of the patient’s cerebral vasculature and robustness of collaterals, a flow-diverting stent was placed with angiographic resolution of the lesion and maintenance of antegrade PICA flow. We present an illustrative case and review the literature surrounding treatment strategies.Ĭase Description: We report a patient presenting with extensive subarachnoid hemorrhage due to rupture of an intracranial VADA involving the PICA origin. Background: Vertebral artery dissecting aneurysm (VADA) involving the origin of the posterior inferior cerebellar artery (PICA) is a complex disease entity in which the dual goals of preventing future rebleeding and maintaining perfusion of the lateral medulla must be considered.
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