Abstract

Postoperative medullary infarctions have been reported as a poor prognostic factor after internal coil trapping of a ruptured vertebral artery dissecting aneurysm (VA-DA). We succeeded in treating a ruptured VA-DA involving the origin of the posterior inferior cerebellar artery (PICA) without critical medullary infarctions. We discuss the reasons why we were able to avoid critical medullary infarctions in this case report.

A 42-year-old Japanese man presented with a sudden onset of left sided headache. He also reported a history of neck pain suddenly occurring two days prior while playing the drum. He had a re-ruptured left VA-DA involving PICA. The re-ruptured VA-DA was initially treated by endovascular bleeding point coil embolization. Dejerine syndrome occurred as a complication of the initial treatment. The neurological symptoms were temporary and the patient made a recovery from the syndrome within a week. MRA revealed recanalization on day 16, and re-bleeding from the ruptured VADA was identified on CT scanning on day 20, which was treated by endovascular proximal coil embolization. Postoperative infarction was noted only in the small area of the left cerebellum. The patient showed marked improvement. On one-year follow-up, the patient remains in good clinical condition (Score 1 on modified Rankin scale).

The bleeding point coil embolization and proximal coil embolization were not performed simultaneously in this case. Decreasing the length of the coil embolization could save the perforating branches.