Scullen Tyler, Mathkour Mansour, Werner Cassidy, Zeoli Tyler, Amenta Peter S
Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
Department of Surgery, Neurosurgery Division, Jazan University, Jazan, Kingdom of Saudi Arabia.
Brain Circ. 2021 Aug 27;7(3):159-166. doi: 10.4103/bc.bc_67_20. eCollection 2021 Jul-Sep.
Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.
颅内夹层假性动脉瘤（IPs）破裂发生率高且神经功能预后差。后循环病变尤其凶险，给治疗带来更大挑战。传统治疗方法包括有或无搭桥的显微外科血管牺牲术。蛛网膜下腔出血（SAH）情况下的血流导向（FD）是一种重建性治疗选择，可与弹簧圈栓塞联合使用以促进病变更快血栓形成。我们报告一例成功通过弹簧圈辅助FD急性治疗的破裂椎动脉（VA）IP病例。一名53岁男性，表现为横跨小脑后下动脉起源的右侧V4段夹层及相关的破裂V4段IP。患者接受了弹簧圈辅助FD治疗。术中开始口服双联抗血小板治疗（DAPT），静脉使用替罗非班作为桥接药物。IP立即闭塞，夹层在48小时内几乎完全消退。患者完全康复，6周时血管造影证实IP完全闭塞、VA重建且支架通畅。在急性SAH情况下使用FD和DAPT仍存在争议。我们认为，在精心挑选的患者中，弹簧圈辅助FD比传统显微外科和血管内治疗选择具有显著优势。通过规划和制定方案，可以有效减轻DAPT带来的风险以及FD导致延迟血栓形成的可能性。我们结合病例讨论当前文献，并回顾治疗这些通常具有毁灭性病变所面临的挑战。
