case_images: PMC9062929_01
case_images: (a) Plain CT shows diffuse subarachnoid hemorrhage, mainly in the prepontine cistern. (b) 3DCTA shows dissecting aneurysm in the left intracranial VA (arrow) and poor depiction of the right VA. (c) Three-dimensional DSA shows wall irregularity and aneurysm formation of the left intracranial VA. (d) The right VAG showed a pearl and string sign on his right VA proximally to PICA origin suggesting dissection. (e) The left internal carotid angiography describes basilar artery and right AICA through posterior communicating artery. (f) The right vertebral angiography shows that the left PICA is patency after parent artery occlusion (arrowhead).
case_images: SNI-13-124-g001.jpg
case_images: PMC9062929_01_SNI-13-124-g001.jpg
case_images: F1
case_images: Head computed tomography (CT) showed a diffuse and symmetrical SAH distributed mainly in the posterior cranial fossa [Figure 1a]. Three-dimensional (3D) CT revealed a fusiform aneurysm of the left intracranial vertebral artery with bleb formation; the right distal vertebral artery and basilar artery were poorly depicted [Figure 1b]. The left vertebral angiography showed a VADA of the left vertebral artery on the V4 segment, proximal to the origin of the posterior inferior cerebellar artery (PICA) [Figure 1c]. The right vertebral angiography showed a pearl-and-string sign on the right vertebral artery proximal to the PICA origin, suggesting another dissection [Figure 1d]. Based on these and other angiographical findings [Figure 1e and f], we focused on the rupture on the left side.
case_images: (a) MRA after PAO shows patency of basilar artery. (b) TOF imaging after PAO demonstrated patency of the right VA and double-lumen sign suggesting dissection, though there was no expanded diameter suggesting aneurysm formation of the right VA. (c and d) The right vertebral angiography POD16 shows that left PICA patency and right VADA progressing revealed.
case_images: SNI-13-124-g002.jpg
case_images: PMC9062929_01_SNI-13-124-g002.jpg
case_images: F2
case_images: On POD 10, follow-up magnetic resonance angiography and time-of-flight imaging demonstrated patency of the right vertebral artery and the double-lumen sign, although the right vertebral artery diameter was not increased [Figure 2a and b]. However, repeat DSA on POD 16 showed that the left vertebral artery remained occluded, and a fusiform aneurysm (8 x 6 mm) was noted at the right V4 segment proximal to the stenosis [Figure 2c and d].
case_images: Schema of the coil embolization with balloon-in-stent technique. (a) After secure distal by stent delivery catheter, wrap coil incompletely. (b) Deploy the stent. (c) Inflate balloon inside stent securing patency and insert coil with jail technique.
case_images: SNI-13-124-g003.jpg
case_images: PMC9062929_01_SNI-13-124-g003.jpg
case_images: F3
case_images: A framing coil (7 mm x 20 cm) was inserted partially through XT-17 [Figure 3], and an LVIS blue stent (4.5 x 10 mm) (MicroVention, Aliso Viejo, CA, USA) was deployed through Headway 21 into the right V4 segment distal to the aneurysm.
case_images: (a) Angiography shows that LVIS blue stent is deployed after wraps coil incompletely. (b) Angiography shows that the balloon in stent is inflated and the coil is embolized. (c) The right VA angiography after stent-assisted coil embolization shows patency of the right VA and BA. (d) MRI shows no DWI high-intensity area.
case_images: SNI-13-124-g004.jpg
case_images: PMC9062929_01_SNI-13-124-g004.jpg
case_images: F4
case_images: Detachable platinum coils were inserted stepwise through the jailed XT-17, while the intravascular lumen was secured by intermittent inflation of the balloon inside the stent [Figure 4a and b]. Finally, intraaneurysmal embolization was completed using 10 coils, and a residual filling of the dome was confirmed on postoperative DSA [Figure 4c]. Postoperative DWI revealed no significant acute thromboembolism [Figure 4d], and no additional neurological symptoms were observed, while the existing symptoms were unchanged.