Vertebral Artery Pseudoaneurysm Research Articles

Vertebral artery pseudoaneurysm: a rare cause of posterior circulation infarction in a middle-aged man.

Pseudoaneurysm of the vertebral artery is a rare cause of posterior circulation stroke. Treatment for this condition can be achieved through microscopic surgery or endovascular therapy. We report a case of a 36-year-old middle-aged male patient who presented with left limb numbness as the sole complaint. On a magnetic resonance imaging examination, multiple infarcts were observed in the left cerebellar tonsil. A subsequent head and neck computed tomography angiography examination led to the diagnosis of a pseudoaneurysm in the left vertebral artery. Following standard antiplatelet therapy, the patient underwent endovascular intervention. The patient's left limb numbness gradually subsided after surgery. A follow-up angiography performed 1 week after discharge showed no recurrence. These findings suggest that covered stent placement is an effective method of treating pseudoaneurysm of the vertebral artery.

Traumatic Pseudoaneurism of the Vertebral and Right Common Carotid Artery Caused by Rare Water Event

Introduction: The pseudoaneurysm of the common carotid artery represents a rare but highly severe clinical entity, particularly when secondary to hydraulic trauma, defined as damage resulting from the impact of high-pressure water, such as that from industrial hoses. This type of trauma is uncommon and often underestimated in its potential to cause significant vascular injuries, including those to vital structures in the neck. Clinical Case: Forty-one-year-old female patient with no significant medical history who 3 weeks ago suffered a closed hydraulic trauma in the right cervical region (high-pressure water coming out of a hose while she was washing her car). A color and spectral Doppler ultrasound of the neck vessels was performed with a high-frequency linear transducer in B mode, which reported: on the right side: pseudo aneurysmal image with a path to the vertebral artery measuring 27 x 23 mm, with Yin-Yang sign on Doppler. A diagnosis of a pseudoaneurysm with arteriovenous fistula (towards the right internal jugular vein) of the right vertebral artery was made. After an adequate anatomical evaluation and surgical planning, an endovascular treatment was decided to be performed. Conclusion: The management of common carotid and vertebral artery pseudoaneurysms secondary to hydraulic trauma involves a nuanced approach, integrating advanced diagnostic imaging and tailored treatment strategies. Both open surgical and endovascular approaches have their respective advantages and limitations. Early recognition, appropriate intervention, and rigorous follow-up are essential to optimize patient outcomes and mitigate risks associated with this challenging condition.

Vertebral Artery Pseudoaneurysm After Extreme Lateral Transcondylar Transodontoid Approach for Clival Chordoma: 2-Dimensional Operative Video

Chordomas can be treated surgically, with radiotherapy, and more recently, chemotherapy. 1,2 A 22-year-old female patient presented with recurrence of a clival chordoma, after subtotal resection at an outside institution 3 months prior. MRI showed a predominantly midline lesion at the craniocervical junction with significant lateral extension eccentric to the left. A 3-staged operation was planned. A redo-endoscopic endonasal transclival transodontoid approach 3-5 was used to resect the midline component, followed by an extreme lateral transcondylar transodontoid approach with transposition of the ipsilateral vertebral artery followed by drilling of the ipsilateral occipital condyle and C1 lateral mass to resect the lateral component, followed by occiput to C3 fusion given the induced craniocervical instability. Careful subperiosteal dissection with preservation of the periosteal sheath overlying the vertebral artery was performed. There was no overt evidence of vertebral artery injury intraoperatively or on immediate postoperative imaging. However, 3 weeks later, the patient presented with blood from the oral/nasal cavity. Computed tomography angiography showed an unexpected left vertebral artery pseudoaneurysm. Pseudoaneurysms can develop after microtears in the muscularis layer. 6-8 Management is based on size, location, and vertebral artery dominance. 9,10 This pseudoaneurysm was coiled. Postcoiling, the patient had left hypoglossal palsy. We demonstrate the step-by-step technique of an extreme lateral transcondylar transodontoid approach for a clival chordoma and the unfortunate complication of a vertebral artery pseudoaneurysm with discussion of its etiology and management options for this potentially devastating complication. The patient consented to the procedure/publication. Institutional Review Board approval not obtained as the patient was deidentified, and no additional risk is posed by the publication of this video.

Delayed Pseudoaneurysms of Vertebral Artery Post Penetrating Trauma: A Case Report

Delayed Pseudoaneurysms of Vertebral Artery Post Penetrating Trauma: A Case Report

Large vertebral artery pseudoaneurysm masquerading as a schwannoma: illustrative case.

Extracranial vertebral aneurysms or pseudoaneurysms are rare and result primarily from trauma. Large pseudoaneurysms can masquerade as mass lesions, making it challenging to identify the correct diagnosis. This is a case report in which a large vertebral pseudoaneurysm posed as a schwannoma and biopsy was attempted. It was later identified as a vascular lesion and treated appropriately with no complications. Vascular etiologies should always be included in the differential diagnosis of spine and nerve pathologies especially lesions that are in the vicinity of major vascular channels such as the transverse foramina of the cervical spine.

Abstract Number ‐ 79: Flow Diversion for Traumatic Vertebral Artery Arteriovenous Fistula: A Case Report

Introduction Arterial pseudoaneurysms and arteriovenous fistulas of intracranial and extracranial vessels are an uncommon occurrence following blunt and penetrating trauma and are commonly treated by vessel sacrifice,dependent on collateral flow1‐3. Others have treated these cases with covered stents4 and flow diversion5. Advances in flow diversion technology have led to their use in other pathologies, including carotid cavernous fistulas6 and vertebral artery pseudoaneurysms7. We present a case of a traumatic arteriovenous fistula of the dominant vertebral artery requiring vessel preservation and reconstruction. Methods A 42‐year‐old male presented with a gunshot wound to the face below the right eye. Trauma imaging identified fractures of the right maxillary sinus and orbital floor. CTA of the head/neck showed a dominant right vertebral artery dissection and pseudoaneurysm with a non‐dominant left vertebral artery (VA), effectively ending in PICA. Results Due to the inefficient supply to the posterior circulation via the left VA, the decision was made to preserve and reconstruct the right VA and the patient was brought to the angiography suite. Angiographically, the patient was noted to have retrograde filling of the posterior circulation, basilar and right VA through the anterior circulation in injection of both ICAs, suggesting decreased antegrade flow from the injured right VA. The right VA was catheterized which showed a high‐flow, high‐grade arteriovenous fistula from the V3 segment with venous drainage into multiple extraspinal cervical and epidural cervical veins. This also identified the fistulous point at the location of the pseudoaneurysm on CTA. The diagnostic catheter was exchanged for a guide catheter, and a Phenom 27 microcatheter (Medtronic; Minneapolis, MN) was navigated into the basilar artery. A Duo microcatheter (Microvention; Aliso Viejo, CA)/Synchro 2 (Stryker; Kalamazoo, MI) standard microwire complex was used to identify the fistulous point and positioned for jailing. A Pipeline Flex 4.75×20mm (Medtronic; Minneapolis, MN) was deployed from the proximal V4 segment across the pseudoaneurysm with persistence of the AVF. A second Pipeline Flex 5×20mm was placed in telescoping fashion with persistence of the AVF. A third Pipeline Flex 5×16mm was placed in telescoping fashion and flow diversion was observed. Using the jailed catheter, the pseudoaneurysm and fistulous point were coil embolized using a combination of helical and 3D HydroSoft coils (Microvention; Aliso Viejo, CA) of varying sizes. Final angiogram demonstrated resolution of the high‐flow AVF, improvement of antegrade flow through the right vertebral artery, and a slow‐flow low‐grade fistulous communication with the posterior extraspinal cervical veins. There were no thromboembolic complications and the patient recovered well from the procedure. Follow‐up angiography at 2 months post‐treatment showed obliteration of the AVF with a small remnant pseudoaneurysm of the right V3 segment. Conclusions Flow diversion is viable in the setting of a traumatic arteriovenous fistula requiring reconstruction of the parent vessel.

Anaesthetic Management of a Spontaneously Ruptured Vertebral Artery Pseudoaneurysm with Dynamic Airway Obstruction

Expanding neck hematoma with progressive airway obstruction is a life-threatening airway emergency. Patients are at risk of cranio-cerebral circulation compromise leading to perioperative cerebrovascular accidents. Furthermore, precipitous fall of blood pressure following neck hematoma exploration mandate the activation of protocols for massive transfusion. We describe the successful anaesthetic management of an extremely rare case of spontaneous rupture of a vertebral artery pseudoaneurysm.

Treatment strategies for patients with concurrent blunt cerebrovascular and traumatic brain injury

Patients who present with traumatic brain injury (TBI) combined with blunt cerebrovascular injuries (BCVI) are difficult to manage, in part because treatment for each entity may exacerbate the other. It is necessary to develop a treatment paradigm that ensures maximum benefit while mitigating the opposing risks. A cohort of 150 patients from 2015 to present, with either internal carotid artery (ICA) and/or vertebral artery (VA) dissections or pseudoaneurysms, was cross-referenced with those who had sustained TBI. Of the 38 patients identified with both TBI and BCVI, 25 suffered ICA injuries, 10 had VA injuries and 3 had combined ICA/VA injuries. Unilateral BCVI occurred in 30 patients, while 8 had bilateral BCVI. Two patients required surgical intervention for TBI, and 5 patients required endovascular intervention for BCVI. Positive emboli detection studies (EDS) on transcranial dopplers (TCD) were demonstrated in 19 patients, with 9 patients having radiographic evidence of stroke. Anti-platelet therapy was initiated in 32 patients, and anti-coagulation in 10 patients, without new or worsening intracranial hemorrhages (ICH). Overall, 76% of patients were able to be discharged home or to rehabilitation, with good recovery demonstrated in 73% of the patients who had appropriate follow-up. In the setting of concurrent TBI and BCVI, use of anti-platelet/coagulation to prevent stroke can be safe if monitored closely. Here we describe a treatment paradigm which weighs the risk and benefits of therapies based on severity of ICH and stroke prevention, which tended to result in good disposition and recovery.

Iatrogenic left vertebral artery pseudoaneurysm treated with a covered stent

Vertebral artery pseudoaneurysm usually occurs after major trauma, but it can arise spontaneously after trivial injury. Clinical manifestations are often related to alterations in the posterior brain circulation. CT and angiography are usually the diagnostic methods of choice. We present a case of a pseudoaneurysm of the left vertebral artery caused by a lesion during a cervical spine surgery and treated with endovascular approach with a covered stent.

Letter to the Editor Regarding “Flow Diverter for the Treatment of Pseudoaneurysms of the Extracranial Vertebral Artery: Report of 2 Cases and Review of the Literature”

Letter to the Editor Regarding “Flow Diverter for the Treatment of Pseudoaneurysms of the Extracranial Vertebral Artery: Report of 2 Cases and Review of the Literature”

Abstract No. 441 VIABAHN stent-graft placement for emergent/urgent cervical cerebrovascular artery disease: a single-center experience of 22 cases

To report our single-center experience of Viabahn stent-graft placement for acute bleeding or pseudoaneurysms of innominate, cervical carotid, or vertebral artery in emergent/urgent clinical conditions. A retrospective study was conducted between Jan 2003 and Sep 2017. A total of 22 patients (14 male, 8 female; age range 18–82 years, mean 55.8 years and median 56 years) were treated with 22 Viabahn stent grafts (9 carotid blow-out syndrome and 13 pseudoaneurysms with or without dissection: 4 innominate, 4 common carotid, 12 internal carotid, 1 both common and internal carotid, and 1 vertebral artery involvement). The stent-graft patency was evaluated by angiogram, contrast-enhanced CT, MRA, ultrasonography, or direct observation during surgery. The mean and median imaging follow-up periods were 740 and 193 days, respectively. Technical success was 100% (22/22). Dual antiplatelet agents were given in 20 patients either immediately before or after the deployment of the stent-grafts. No immediate procedure-related complications occurred. Two unstable patients with carotid blow-out syndrome died of severe systemic disturbance within 8 days, despite successful bleeding cessation by the procedure. Three patients underwent subsequent bypass surgery within 17 days for concern about infection. One stent-graft occlusion occurred 195 days after the procedure with unexpected cession of antiplatelet therapy. One significant hemorrhagic complication was observed and died 125 days after the procedure (esophagocutaneous fistula). Two patients were lost to follow-up. Among the remaining 13 patients, 11 patients demonstrated 6 months or longer stent-graft patency and 2 developed more than 50% stenosis. Viabahn stent-grafting may be safe and useful for the management of emergent/urgent arterial bleeding or pseudoaneurysms involving cervical cerebrovascular arteries.

High-resolution magnetic resonance imaging of intracranial aneurysms treated by flow diversion

Abstract Object Flow diverter treatment of intracerebral aneurysms is highly successful and has low rates of morbidity and mortality. Among the primary concerns after endovascular treatment are failure to achieve aneurysm obliteration and recurrence, and close imaging follow-up is required. High-resolution magnetic resonance imaging (HRMRI) is being employed in evaluation of an increasingly wide variety of pathological conditions, but investigations into its use after flow diversion for aneurysm treatment have been limited. We present a brief overview of the literature on the use of HRMRI as a follow-up tool after aneurysm treatment using flow diversion, along with a case series describing three patients in whom we used HRMRI to assess aneurysm treatment response. Case descriptions Patient 1 presented with an ischemic stroke and was found to have an unruptured ophthalmic segment aneurysm. Patient 2 presented with subarachnoid hemorrhage from a ruptured vertebral artery pseudoaneurysm. Patient 3, on workup for possible metastatic melanoma, was found to have an unruptured posterior communicating aneurysm. All three were treated with flow diversion, and in all three cases HRMRI was used to evaluate aneurysm obliteration on outpatient follow-up. HRMRI offered excellent resolution of the parent vessel, aneurysm sac, and aneurysm wall, demonstrating decreased or loss of flow-related enhancement in the aneurysm lumen and development of aneurysm sac thrombosis. Conclusion HRMRI is a useful tool to evaluate aneurysm treatment by flow diversion and may represent an alternative to repeat digital subtraction angiography.

Iatrogenic Vascular Injuries Due to Spinal Surgeries: Endovascular Perspective.

Iatrogenic vascular injuries due to spinal surgeries are rare but serious complications. Surgical management of these injuries is challenging with high morbidity rates. In this study we aim to present the results of endovascular management of iatrogenic vascular injuries due to spinal surgeries. We retrospectively reviewed 11 patients (5 male, 6 female) who had vascular injuries due to cervical and lumbar spinal surgeries. Clinical findings were bleeding (n=5), leg edema (n=6) and right heart failure with severe dyspnea (n=1). The age range of the patients were between 42-67 (mean: 57.1). Six patients were reviewed with imaging before the procedures and the rest of the patients (n=5) were directly referred to the angiography unit for diagnosis and possible endovascular treatment. The types of surgeries were; cervical surgery (n=5) and lumbar disc operation (n=6). The type of vascular injuries were; vertebral artery stenosis (n=1), vertebral artery pseudoaneurysm (n=3), vertebral artery occlusion (n=1) and iliac arteriovenous fistula (n=6). The type of endovascular treatments were; parent artery occlusion (PAO) (n=2), covered stent graft implantation (n=6) and intrasaccular coil embolization of pseudoaneurysm (n=1). The remaining 2 patients were managed conservatively. No major complications or mortality occured during endovascular interventions. No bleeding or ischemia occured in the follow-up period. Iatrogenic vascular injuries due to spinal surgeries are rare but serious complications. Endovascular interventions are safe and effective in the diagnosis and treatment of such vascular injuries.

Successful Treatment of Iatrogenic Vertebral Artery Pseudoaneurysm with Coil Embolization: Case Report

Introduction: Iatrogenic vertebral artery injury (IVAI) is a rare intricacy during cervical spine screw fixation or removal surgery. The overall incidence of vertebral artery (VA) injury related to craniocervical surgery is about 0.2% in literature.Case presentation: We report a case of 52-year-old male who suffered iatrogenic vertebral artery injury (VAI) as a result of surgical removal of C1-2 screw that was successfully fixed at posterior cervical spine on account of traumatic atlantoaxial dislocation four (4) years ago. The surgical removal was on going at a periphery hospital when the patient suffered this intricacy with massive bleeding. He was immediately transferred to our facility. CT angiography done at our facility revealed a pseudoaneurysm measuring about 5.5 cm in diameter at the cervical region.Conclusions: We successfully treated this pseudoaneurysm with coil embolization without any further neurological deficits. Although the occurrence of iatrogenic VAI pseudoaneurysm as a result of the removal of C1-2 screw is extremely rare, it occurrence can be very fetal with very serious neurological deficits or death.

Treatment of a giant vertebral artery pseudoaneurysm secondary to gunshot wound to the neck using pipeline embolization device

Treatment of a giant vertebral artery pseudoaneurysm secondary to gunshot wound to the neck using pipeline embolization device

Posterior pedicle fixation with polyaxial screws and rods for combined fractures of the atlas and axis

Objective To investigate the clinical outcomes of posterior pedicle fixation (C1-C2 pedicle fixation or C1-C3 pedicle fixation) with polyaxial screws and rods for combined fractures of the atlas and axis. Methods From August 2007 to May 2014, we treated 24 patients with combined fractures of the atlas and axis using posterior pedicle fixation with polyaxial screws and rods. There were 10 cases of C1-odontoid Type Ⅱfracture, 4 cases of C1-miscellaneous C2 fracture, 4 cases of C1-odontoid Type Ⅲ fracture, and 6 cases of C1-hangman's fracture. Posterior C1-C2 pedicle fixation was adopted in 16 cases and posterior C1-C3 pedicle fix-ation in 8 cases to stabilize the atlas and axis. The clinical and radiological outcomes were evaluated using to the visual analogue scale (VAS), Frankel grading, neck disability index(NDI) and Japanese Orthopaedic Associa-tion (JOA) scores. Graft fusion and operative complications were documented. Results The operative time ranged from 90 to 170 min (mean, 123 min); the blood loss ranged from 290 to 750 mL (mean, 427 mL). The patients were followed up for 15 to 45 months (mean, 27 months). Bony fusion was achieved within 9 months (mean, 4.7 months). The Frankel grading was improved in all the 10 patients with neural deficits. The pre-operative VAS, NDI and JOA scores (6.8±1.0, 41.4±1.6 and 8.6±1.0, respectively) were significantly improved to 1.6±0.7, 11.2±1.9 and 15.3±1.2, respectively (P<0.05). The rates of JOA improvement averaged 78.5%, ranging from 60.0% to 87.5%. One patient suffered hemorrhage from a pseudoaneurysm of the injured vertebral artery 2 days after surgery. No such complications happened as implant failure, fracture nonunion, spinal cord injury, cerebrospinal fluid leakage or wound infection. Conclusions Posterior pedicle fixation with polyaxial screws and rods is an effective and relatively safe technique for combined fractures of the atlas and axis, because it can reduce the fracture, restore cervical sequence, fixate firmly, and lead to a high rate of graft fusion. Digital subtraction angiography and interventional embolization is feasible and effective if hemorrhage from a pseudoaneurysm occurs due to vertebral artery injury postoperatively. Key words: Atlas; Axis; Fractures, bone; Fracture fixation, internal; Pedicle screw fixation

Vertebral artery pseudoaneurysms secondary to blunt trauma: Endovascular management by means of neurostents and flow diverters

Extracranial vertebral pseudoaneurysms that develop following blunt trauma to the cervical area may have a benign course; however, embolic or ischemic stroke and progressive pseudoaneurysm enlargement may occur. We review the presentation and endovascular management of pseudoaneurysms of the cervical vertebral artery (VA) due to blunt trauma in nine patients (eight male, mean age 27years). Pseudoaneurysms occurred in dominant vessels in seven patients and coexisted with segmental narrowing in six. We favored endovascular intervention during the acute phase only in cases with significant narrowing of a dominant VA, especially when anticoagulation was contraindicated. Four patients were treated during the acute stage (contraindication to anticoagulation, mass effect, severely injured dominant VA/impending stroke); five during the chronic phase (pseudoaneurysm growth, ischemic stroke on aspirin prophylaxis, patient preference). Reconstructive techniques were favored over deliberate endovascular occlusion when dominant vessels were involved. Arterial reconstruction was performed in eight of nine patients using a flow-diverter implant (5 patients), stent-assisted coiling (1), overlapping stent implant (1), or implantation of a balloon-expandable stent (1). Deliberate VA occlusion with coils was performed in one of nine patients due to suboptimal expansion of the stented artery after flow-diverter implant. No neurological complications occurred during follow-up. All cases treated by reconstructive techniques showed complete, persistent pseudoaneurysm occlusion and full arterial patency. Endovascular therapy of traumatic VA pseudoaneurysms using neurostents and flow-diverters resulted in occlusion of the pseudoaneurysms, preservation of the parent vessel, and no periprocedural or delayed clinical complications, supporting the feasibility and safety of the approach.

An Unusual Posttraumatic Pseudoaneurysm of Intracranial Segment (V4) of the Vertebral Artery

Traumatic pseudoaneurysm of the vertebral artery is an uncommon and one of the most difficult lesions to treat. Posttraumatic vertebral artery pseudoaneurysm is located mostly extracranially, and its intracranial occurrence is exceedingly rare. We report a case of an 18-year-old man who underwent successful treatment of posttraumatic intracranial pseudoaneurysm of V4 segment of the vertebral artery by endovascular embolization. The patient who sustained trauma in a road accident presented with the complaints of headache, giddiness, and vomiting for the last 13 days. On admission, he was conscious but drowsy with no focal neurologic deficit. CT scan of the brain was suggestive of no significant intracranial abnormality. As the patient had headache, vomiting, and drowsiness, the CT was unable to explain his clinical picture, so CT angiography was performed to exclude vascular abnormality. CT angiography of the brain was suggestive of left vertebral artery aneurysm arising from V4 segment of the left vertebral artery. DSA showed a large pseudoaneurysm arising from left V4 segment of the vertebral artery near origin of PICA. Because of its difficult location, surgical treatment is less preferable as compared with endovascular treatment. The patient underwent endovascular coiling of pseudoaneurysm. Postcoiling DSA showed complete occlusion of pseudoaneurysm. The patient had uneventful postoperative period and showed good recovery.

Postpartum spinal subdural hematoma: irrelevant epidural blood patch: a case report.

We report a healthy patient with postpartum headache and neck stiffness which were diagnosed as symptoms of pseudoaneurysm of vertebral artery. She had received a Cesarean section under the spinal anesthesia, and complaint of headache and neck stiffness. Epidural blood patches were done twice, but symptoms persisted. Eight days later, she experienced sensory disturbance and emergent laminectomy was done. When persistent postpartum headache occurs after epidural blood patch, more precise differential diagnosis should be made and considering other possible pathologies.

Application of Pipeline Embolization Device for Iatrogenic Pseudoaneurysms of the Extracranial Vertebral Artery: A Case Report and Systematic Review of the Literature.

Traumatic pseudoaneurysms of the vertebral artery (VA) are uncommon vascular lesions and definitive management is often challenging. Between 0% and 8% of craniocervical fusions are complicated by VA injury. In these cases, preserving the vertebral artery while treating the pseudoaneurysm is the goal of any treatment option. We describe the second known case of a patient with and iatrogenic extracranial vertebral artery pseudoaneurysm treated effectively using the Pipeline Embolization Device (PED) (Ev3 Neurovascular, Irvine, CA). Although there have been only two cases reported, the use of flow-diverting stents appears to be efficacious for the treatment of non-actively bleeding traumatic pseudoaneurysms.