Dissecting aneurysm of the V4 segment of the vertebral artery

Case contributed by Dr Bruno Di Muzio

Presentation

Sudden and the worse headache ever. Grade IV SAH was identified on a secondary hospital CT. The patient was transferred to a tertiary centre to further treatment and investigation.

Patient Data

Age: 60-year-old
Gender: Male
DSA (angiography)

Cerebral angiogram (DSA) - selected images

Procedure and findings: Intubated patient brought from from ICU after EVD insertion. With informed consent.

Right groin approach ( 5-French sheath ) bilateral common carotid, and vertebral artery angiography was performed with 3D acquisition of the left vertebral. A dissecting aneurysm of the V4 segment of the left vertebral artery distal to the left PICA origin. The dissection appears to extend up to the proximal basilar as well. The aneurysm measures 8.9x6.7 mm in dimensions. Both PCOM are prominant with good cross circulation. No other aneurysms, arteriovenous malformation or dAVF present.Haemostasis with 6F angioseal.

Conclusion: Dissecting aneurysm involving the V4 segment of the left vertebral artery with dissection extending to the proximal basilar artery. ​

New right gaze palsy and left pupil non-reactive

Technique: Non-contrast images through the brain have been obtained.

Findings: Reference is made with previous DSA. Comparison is made with external CT (not shown).

Hyperdense subarachnoid haemorrhage is seen predominantly surrounding the brainstem and extending inferiorly through the foreman magnum surrounding the basilar artery in keeping with site of dissection. Haemorrhage is also seen within the perimesencephalic cisterns, left sylvian fissure, temporal horns of the lateral ventricles, third and fourth ventricles. There has been redistribution of blood products but no evidence of interval bleed.

No subfalcine, tonsillar or uncal herniation.

Right frontal approach EVD terminates inferior to the anterior horn of the left lateral ventricle. Ventricular pattern is stable. No evidence of acute ischaemia.

Conclusion: Extensive subarachnoid haemorrhage in keeping with vertebral and basilar artery dissection. No interval haemorrhage evident.

Case Discussion

This case illustrates a distal vertebral artery dissecting aneurysm and related SAH.

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Case information

rID: 41112
Case created: 16th Nov 2015
Last edited: 24th Jan 2016
Tag: rmh
Inclusion in quiz mode: Included

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