出血発症のＰＩＣＡ ｉｎｖｏｌｖｅｄ ｄｉｓｓｅｃｔｉｏｎ ａｎｅｕｒｙｓｍ 出血発症のＰＩＣＡ ｉｎｖｏｌｖｉｎｇ ｄｉｓｓｅｃｔｉｎｇ ａｎｅｕｒｙｓｍの治療―順行性血行を生かした近位部母血管閉塞術―

Abstract

Ruptured vertebral artery dissecting aneurysm (VADA) requires urgent treatment because of the high incidence of re-bleeding, especially during the first 24 hours. Among such cases lesions involving the origin of the posterior inferior cerebellar artery (PICA) are formidable because it is difficult to prevent rebleeding and preserve blood flow of the PICA in the acute stage. We report a representative case in which we tried a simple and effective therapeutic method for these cases. A 38-year-old man was admitted to our hospital suffering severe headache, vomiting, and loss of consciousness. CT scan revealed subarachnoid hemorrhage, but soon after, rebleeding occurred and he fell into a deep coma. After waiting until the chronic stage when he recovered, we performed cerebral angiography. A left vertebral angiogram demonstrated a dissecting aneurysm involving the origin of the PICA. We occluded the affected vertebral artery (VA) near its root with platinum coils, intending to introduce collateral blood flow from the deep cervical artery into the VA trunk. We thought the controlled antegrade VA flow and retrograde flow from the contralateral VA would make a watershed at the dissecting aneurysm, which promotes thrombosis of the pseudo-lumen while preserving the antegrade flow of the PICA. After treatment, the dissecting aneurysm disappeared on angiogram and the patient recovered without rebleeding or ischemic complication. This method should be considered as the treatment of choice in cases with VADA involving PICA.