PMC8769405_01
(A) Axial head CT scan revealed a subarachnoid hemorrhage (Fisher grade 3). (B) MRA of the onset. The image shows an aneurysm and occluded bilateral VA. (C) MRA taken 8 years prior at our hospital showed bilateral VA, but with severe stenosis in the proximal VA. CT: computed tomography, MRA: magnetic resonance angiography, VA: vertebral artery.
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F1
Computed tomography (CT) showed a Fisher 3 subarachnoid hemorrhage (Fig. 1A). Magnetic resonance angiography (MRA) revealed abnormal vascular lesion (Fig. 1B), which was suspected to be a bleeding point. The MRA at 8 years prior to this case showed the right VA was stenotic and left VA was patent (Fig. 1C).
(A) A-P and (B) lateral views of the right vertebral angiography on admission. High-grade atherosclerotic wall irregularities were found. The right vertebral artery was occluded at the extracranial segment while the ASA bifurcated at the level of the fourth vertebral body. The ASA was dilated and perfused the circulation area of the vertebral basilar artery. An aneurysm was noted at the intracranial portion of the dilated ASA (arrow head). ASA: anterior spinal artery.
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F2
Digital subtraction angiography (DSA) showed an aneurysm at the intracranial junction of the dilated ASA (Figs. 2A and 2B), which was irregularly shaped, and a broad neck aneurysm (6.0 mm x 5.0 mm).
(A) A-P view. The microcatheter tip was introduced into the aneurysm, and angiography was performed. Right vertebral angiography was performed after coil embolization. (B) After embolization of the aneurysm, adequate blood flow of the vertebrobasilar artery was confirmed. (C) Lateral views of the right vertebral angiography after 3 months. The arrowhead is the part where the aneurysm was not visualized.
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F3
When the tip of the Excelsior SL-10 microcatheter was placed into position and the aneurysm was imaged again, the basilar artery was visualized with the aneurysm, and it was confirmed that no contrast agent remained (Fig. 3A). The coil part of the aneurysm was not imaged, whereas the bleb was imaged with a slight delay (Fig. 3B). DSA performed 3 months later confirmed the patency of the ASA and disappearance of the aneurysm (Fig. 3C).