INR scope

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

Authors: ALQAHTANI Alwaleed, ALORAINI Ziad

Discover the case of a 35-year-old female patient with ruptured bilateral spontaneous intradural vertebral artery dissection, resulting in a V4 segment false aneurysm. The medical team devised a two-stage neurointerventional plan involving VP shunt insertion and flow-diverter stenting to treat the aneurysm. 

Wednesday 24 May 2023
  • Case presentation

    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





    • 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.





    Second Stage



    Two-Weeks Follow-up



    • 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.
  • Conclusion
    • 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.
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