Endovascular management of subarachnoid hemorrhage due to vertebrobasilar artery dissection using emergency flow-diverter stent placement combined with pseudoaneurysm coiling.

BACKGROUND

Subarachnoid hemorrhage (SAH) due to intracranial dissecting aneurysm is uncommon and may be challenging to secure when conventional clipping, coiling, or parent artery occlusion are not feasible. Flow-diverter stents have recently emerged as a rescue option in ruptured aneurysms, but their use in the acute phase remains controversial. We report a complex vertebrobasilar dissection presenting with aneurysmal SAH that was successfully treated with emergency flow diversion and adjunctive coiling.

CASE DESCRIPTION: A 54-year-old man with untreated hypertension presented comatose with diffuse SAH. CT angiography and digital subtraction angiography demonstrated a dominant right vertebral artery with a long-segment vertebrobasilar dissection, a large ruptured pseudoaneurysm at the vertebrobasilar junction, and a small aneurysm at the ipsilateral PICA origin, with hypoplastic contralateral vertebral artery. The anatomy precluded clipping, coiling alone, or parent vessel sacrifice. After loading doses of aspirin and clopidogrel, a Derivo2 flow-diverter stent was deployed from the proximal basilar artery to the V4 segment of the right vertebral artery, and the ruptured pseudoaneurysm was selectively coiled. Acute distal in-stent thrombosis was managed with balloon angioplasty and intravenous heparin. The patient awoke promptly and was extubated 6 hours later. Follow-up MRI at 12 hours showed a patent stent, complete exclusion of the pseudoaneurysm, and no SAH progression.

CONCLUSION

This case illustrates that emergency flow diversion with adjunctive coiling can be a feasible strategy for ruptured vertebrobasilar dissecting pseudoaneurysms in carefully selected patients when conventional surgical or endovascular strategies are not feasible.