Murai Yasuo, Matano Fumihiro, Yokobori Shoji, Onda Hidetaka, Yokota Hiroyuki, Morita Akio
Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan.
Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan.
World Neurosurg. 2017 Oct;106:1050.e11-1050.e20. doi: 10.1016/j.wneu.2017.06.167. Epub 2017 Jul 12.
Bilateral vertebral artery dissection (VAD) may result in subarachnoid hemorrhage (SAH). However, a variety of factors contribute to the difficulties with treating SAH. We report a case of bilateral VAD with SAH, as well as a literature review.
A 32-year-old woman developed headache. Computed tomography demonstrated diffuse SAH, and 3-dimensional computed tomography indicated bilateral VAD. Her left vertebral artery was severely stenosed, and the basilar artery retrogradely flowed via the posterior communicating artery. Her bilateral VAD was trapped with the use of staged craniotomy. The postoperative course was uneventful for 13 days; however, severe neurologic deterioration remained in the area of the cerebral infarction, due to vasospasm of the internal carotid artery. This is the first report of hemorrhagic bilateral VAD treated with bilateral trapping and aggressive spasm treatment in the acute phase. However, the treatment was not successful.
Because of the increasing use of stent therapy, there has been a shift toward this treatment choice. For cases in which stents cannot be used, treatment methods based on prestenting protocols are helpful. A literature review indicated that conservative treatment for 2 weeks, in which vasospasm and rebleeding are controlled, may be considered compared with acute-stage stent treatment. Following our literature review, in situations in which stents cannot be used, only the ruptured side should be trapped with strict blood pressure control and detailed radiological images should be observed for 2 weeks. In conclusion, patient selection is essential to subject the patient to open surgery in such cases.
双侧椎动脉夹层（VAD）可能导致蛛网膜下腔出血（SAH）。然而，多种因素导致SAH治疗困难。我们报告一例双侧VAD合并SAH病例及文献综述。
一名32岁女性出现头痛。计算机断层扫描显示弥漫性SAH，三维计算机断层扫描显示双侧VAD。其左侧椎动脉严重狭窄，基底动脉通过后交通动脉逆向血流。通过分期开颅手术对其双侧VAD进行夹闭。术后13天病情平稳；然而，由于颈内动脉血管痉挛，脑梗死区域仍存在严重神经功能恶化。这是首例在急性期采用双侧夹闭和积极痉挛治疗的出血性双侧VAD报告。然而，治疗未成功。
由于支架治疗的应用增加，治疗选择已转向这种方法。对于无法使用支架的病例，基于支架置入前方案的治疗方法是有帮助的。文献综述表明，与急性期支架治疗相比，可考虑进行为期2周的保守治疗，以控制血管痉挛和再出血。根据我们的文献综述，在无法使用支架的情况下，仅夹闭破裂侧，严格控制血压，并观察详细的影像学图像2周。总之，在这类病例中，患者选择对于是否让患者接受开放手术至关重要。
