Ruptured bilateral spontaneous intradural vertebral artery dissection treated by flow-diverter with a special caution of the fish-mouth phenomena

Patient presentation

• A 35-year-old female patient known case of hypertension not adherent to treatment.
• Presented to E.R. C/O:
  • severe headache for one day, altered mental status, vomiting, and drowsiness. 
• While preparing to be pushed to CT scan: 
  • she developed seizure and sudden drop in her Glasgow coma scale to be 3 out of 15. Thus, urgent intubation was performed. Stroke code was activated

Planning

• Urgent VP shunt insertion was performed.
• MDT:
  • Ensure Stability of the pt.
  • To proceed for neurointervention with consideration of high-risk mortality.
  • As we planned for flow-diverter stenting the procedure will be on two stages.
  • If sacrificed one Vert, the other one is maintaining the flow to the BA.
  • To assess the patency of RT Vert after stenting and augmentation.
  • Monitoring for fish-mouth phenomena.
  • Three days time interval.

Intervention

Procedural Steps

• Start the patient on DATP 3 hours before the procedure.
  • Loading dose Aspirin 300 mg once.
  • Loading dose 180mg once.
• Aggrastat (15 ml) is prepared and kept on standby.
• First to perform DSA and calculating proper size.
• The flow-diverter stents used:
  • SILK VISTA 3.5X2 mm.

First-Stage

Second Stage

Two-Weeks Follow-up

Discharge

• The patient kept on DTAP and still sedated on mechanical ventilator until 2 weeks.
• She weaned off sedation with gradual regain of consciousness level.
• The patient was discharged after full recovery and intact neurological exam.
• GCS is 15/15.
• Aspirin 90 mg po BID for the next 6 months.
• Then, 80 mg once for life.

• Flow-diverter stenting appears to be safe and effective in treating posterior circulation dissecting false aneurysm.
• Proper sizing must be encountered to prevent development of fish-mouth phenomena.
• Further large systemic review studies are mandated.