PMC7749953_01
Axial CT brain showing modified Fischer grade 3 SAH in prepontine cistern (black arrow) (a). Right vertebral artery injection showing saccular aneurysm at vertebrobasilar (VB) junction (black arrow) with retrograde flow of contrast in left subclavian (b). 3D rotational angiogram showing saccular aneurysm arising from VB junction. (c) Long sheath injection from the right subclavian artery showing aneurysm in VB junction with retrograde flow in the left vertebral artery (black arrow) (d), next frame of previous run showing progressive retrograde filling of left vertebral artery till its origin from left subclavian artery (black arrow) (e). Aortogram showing tight stenosis of left subclavian origin (black arrow) (f).
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F1
Non-enhanced computed tomography (CT) scan of the brain showed modified Fisher Grade 3 subarachnoid hemorrhage (SAH) in the prepontine cistern [Figure 1]. There was a small teat projecting downward from the dome of the aneurysm [Figure 1]. On right vertebral angiogram, there was retrograde filling of the left vertebral artery till its origin from the left subclavian artery [Figure 1]. Descending thoracic aortogram showed near-complete occlusion of the left subclavian artery origin [Figure 1].
Post angioplasty left subclavian injection showing anterograde flow in the left vertebral artery with filling of aneurysm (a). AP projection of the left vertebral injection after deployment of the first coil in the aneurysm sac (b). Lateral projection of the left vertebral injection after deployment of second coil showing minimal neck residue (black arrow) (c). Post coiling aortogram taken with long sheath in descending thoracic aorta showing residual stenosis at the left subclavian origin (d) note mild opening of the stenosis due to long sheath placement.
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F2
Postcoiling angiogram showed Modified Raymond-Roy Class II occlusion of the aneurysm with normal filling of all vessels [Figure 2]. Descending thoracic aortogram showed partial opening of the stenotic origin of the left subclavian artery [Figure 2] The 7F long sheath was removed and hemostasis achieved by manual compression.