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. 

• 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

  

   

  

   

  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

  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.
• 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.