PMC9119691_01
(A) Magnetic resonance angiography (MRA) performed 10 years previously shows normal right vertebral artery (VA). (B) MRA performed 3 weeks before the vaccination shows dilatation of the right VA (arrowhead). (C) Fluid-attenuated inversion recovery magnetic resonance imaging (MRI) performed on the same day shows no intracranial hemorrhage. (D) Head computed tomography (CT) performed 1 day after the vaccination shows diffuse subarachnoid hemorrhage. (E) Chest CT performed on the same day shows bilateral pulmonary effusion. (F) Three-dimensional CT angiography (3DCTA) performed on the same day shows dissecting aneurysm in the right VA (arrowhead). The right posterior inferior cerebellar artery (PICA) originated from the extradural segment of the VA (arrow).
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A 60-year-old woman with a previous history of dyslipidemia incidentally underwent magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) 10 years previously that showed no abnormality in the vertebral artery (VA) (Fig. 1A). Although MRA showed dilatation of the right VA (Fig. 1B), MRI showed no intracranial hemorrhage (Fig. 1C). Brain computed tomography (CT) showed massive subarachnoid hemorrhage (Fig. 1D), and chest CT revealed bilateral pulmonary effusion due to neurogenic cardiomyopathy (Fig. 1E). T waves in V3-V6, the transthoracic echocardiogram showed mild hypokinesia of the apex without reduced ejection fraction. Three-dimensional CT angiography (3DCTA) of the head showed fusiform dilatation of the right VA, suggesting dissecting aneurysm (Fig. 1F).
(A) Frontal view of the right vertebral artery angiography (VAG) before internal trapping shows dissecting aneurysm in the right VA. (B) Frontal view of the right VAG after internal trapping reveals that the dissecting lesion was occluded just distal to the origin of the right posterior inferior cerebellar artery (PICA). (C) Frontal view of the left VAG after internal trapping also reveals that the dissecting lesion was occluded. (D) Postoperative magnetic resonance angiography (MRA) performed 2 weeks after treatment reveals that the dissecting lesion of the right VA was not visualized.
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The procedure was performed under general anesthesia (Fig. 2A). Both right and left VA angiography after internal trapping revealed that the dissecting lesion was not visualized (Fig. 2B and C). Postoperative MRI showed no evident complications of the internal trapping procedures, and the dissecting lesion of the right VA was not visualized on MRA (Fig. 2D).
PMC9119691_02
(A) Head computed tomography (CT) performed 7 days after vaccination shows massive subarachnoid hemorrhage in the posterior cranial fossa. (B) Three-dimensional CT angiography (3DCTA) performed on the same day shows a dissecting aneurysm with bleb-like protrusion on the right vertebral artery (VA). (C) Magnetic resonance angiography (MRA) performed 1 year previously shows caliber change of the right VA, retrospectively, suggesting chronic arterial dissection.
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Brain CT showed subarachnoid hemorrhage mainly in the posterior cranial fossa (Fig. 3A). 3DCTA showed a dissecting aneurysm with bleb-like protrusion on the right VA (Fig. 3B). Retrospectively, MRA performed 1 year previously showed caliber change of the right VA, suggesting that there had been a chronic arterial dissection (Fig. 3C).
(A) Frontal view of the right vertebral artery angiography (VAG) before stent-assisted coil embolization shows dissecting aneurysm in the right vertebral artery (VA) involving the right posterior inferior cerebellar artery (PICA). (B) Frontal view of the right VAG after stent-assisted coil embolization shows coil occlusion of the aneurysmal sac and patency of the right VA and right PICA. (C) Cone beam computed tomography (CT) image shows the bladed stent placed across the dissecting lesion and coils deployed into the sac. (D) Postoperative magnetic resonance angiography (MRA) performed 2 weeks after treatment shows that the dissecting aneurysm is not visualized and the right PICA is patent.
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The off-label use of intracranial stents was approved by our institutional ethical committee, and written informed consent was obtained before the procedure, which was performed under general anesthesia (Fig. 4A). A 3.5 x 17 mm bladed stent (MicroVention Terumo, Tustin, CA, USA) was placed across the dissecting lesion, and detachable coils were deployed into the aneurysmal sac (Fig. 4B and C). Postoperative MRI showed no evident complications, and the dissecting aneurysm was not visualized on MRA (Fig. 4D).