37/F

Spontaneous Subarachnoid
Hemorrhage
 Episodic headache with blurring of
vision and giddiness- 4 months
 Sudden onset of severe headache
followed by brief loc on
20.11.2009.
 Headache lasted 4 days, recovery
complete
 NCCT head –Normal
 Repeat episode of severe headache with
loc for 15 mins on 27.11.2009.
 Headache persisted for 1 week
 NCCT head – Fourth ventricular bleed
with ?subarachnoid hemorrhage in
bilateral CP angle cistern (R>L).
Examination

 No neurological deficit
 Neck rigidity present
Imaging
 CT angiography:
 CT angio : Right vertebral artery
fusiform aneurysm.
 IADSA
Right Left
V.A. V.A.
RVA- AP LVA-AP

RVA- LVA-Lat
Lat
 PCOM
PCOM

RICA LICA
 IADSA :
– Fusiform aneurysm right vertebral
artery.
– Beaded appearance of bilateral
extracranial vertebral artery upto PICA
and involvement of external carotid
artery branches.
– Renal artery and aorta were normal.
Treatment Options
 No intervention
 Surgical clipping of aneurysm
 Stenting with coiling of aneurysm
 Occluding the right vertebral
artery
No Intervention
 PROS
– Extensive involvement.
– Neurologically intact

 CONS:
– Risk of rebleeding, similar to any other
ruptured aneurysm.
Surgical clipping
 PROS
– Direct treatment.

 CONS
– Extensive involvement of vertebral
artery
– Difficult technically as all the walls
involved (blow out)
Right vertebral artery
occlusion
 PROS:
– Flow reversal leading to obliteration
of aneurysm.
– Extensive involvement of vertebral
artery dealt with.
 CONS:
– Risk of ischemia.
Stenting with coiling of
aneurysm
 PROS:
– Direct treatment of the aneurysm

 CONS:
– Difficult to negotiate catheter through
the involved beaded segment without
causing dissection or bleeding.
Concerns
 Extensive involvement of bilateral
vertebral and external carotid artery
branches.
 Poor flow in posterior communicating
artery
 Large ruptured intracranial fusiform
aneurysm just near the right PICA.
 If later on left vertebral artery involves,
chances of ischemia.
 RVA- AP
(30.11.2009)

RVA- AP (07.12.2009)
RVA -Lat
LVA- AP
RICA- AP LICA - AP
Post Nimodipin
Post occlusion
 Post occlusion

Pre-occlusion
Occluded Rt VA
Fibromuscular
Dysplasia
 FMD is an angiopathy that affects medium-
sized arteries predominantly in young
women of childbearing age.
 FMD most commonly affects the renal
arteries and can cause refractory
renovascular hypertension.
 Renal involvement occurs in 60-75%,
 Cerebrovascular involvement occurs
in 25-30%,
 Visceral involvement occurs in 9%
 Arteries of the limbs are affected in
about 5%
 26% of patients, disease is found in
more than one arterial region
 Cephalic FMD: 95% have internal
carotid artery involvement and 12-
43% have vertebral artery
involvement.
 Involvement of smaller blood
vessels, including intracranial
vessels, is rare.
 FMD is an important cause of
stroke in young adults.
 Prevalence of aneurysms- 7.3%.
 FMD is a predisposing factor in
15% of spontaneous cervical
carotid dissections.
D/D
 Moyamoya Disease
Neurosyphilis
Takayasu Arteritis
Varicella Zoster
Vasculitic Neuropathy
Treatment
 According to presentation and
pathology
– Stroke.
– Dissection.
– SAH with aneurysm.