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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 1  |  Page : 184-186

Endovascular Treatment of a Primary Extracranial Vertebral Artery Aneurysm Causing Ischemic Stroke


Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China

Date of Submission13-Jun-2018
Date of Decision19-Mar-2020
Date of Acceptance30-Mar-2020
Date of Web Publication24-Feb-2021

Correspondence Address:
Yabing Wang
Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng district, 100053, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.310099

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 » Abstract 


Background and Aims: Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; various surgical and endovascular treatment options are available.
Methods: We report a 44-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. The patient presented with brainstem infarction, and the diagnosis of primary extracranial vertebral artery aneurysm was made by computed tomography angiography (CTA).
Results: This patient's aneurysm was definitively treated using an endovascular approach with placement of a covered stent in the right proximal vertebral artery.
Conclusion: Although aneurysms of this location are traditionally repaired with open aneurysmectomy, we show that endovascular treatment can be a safe and effective alternative approach. In the case reported here, primary extracranial vertebral artery aneurysm presenting with embolic stroke was successfully treated with a covered stent. Complete exclusion of the aneurysm from blood circulation is advisable to achieve full resolution of the embolic source.


Keywords: Stent, vertebral artery aneurysm, stroke
Key Message: Extracranial vertebral artery aneurysms are very uncommon. Endovascular treatment is a good option for treating complex vertebral artery aneurysm.


How to cite this article:
Wang Y, Jiao L. Endovascular Treatment of a Primary Extracranial Vertebral Artery Aneurysm Causing Ischemic Stroke. Neurol India 2021;69:184-6

How to cite this URL:
Wang Y, Jiao L. Endovascular Treatment of a Primary Extracranial Vertebral Artery Aneurysm Causing Ischemic Stroke. Neurol India [serial online] 2021 [cited 2021 May 6];69:184-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/1/184/310099




We report an endovascular approach that was used to treat a symptomatic extracranial vertebral artery aneurysm. A 44-year-old male patient presented with brainstem infarction confirmed by cranial magnetic resonance imaging (MRI). CT angiography (CTA) demonstrated a right proximal extracranial vertebral artery aneurysm. The patient underwent endovascular exclusion of the vertebral artery aneurysm using a covered stent. The 12-month follow-up CT scan confirmed patency of the stent and intracranial vessels. Endovascular treatment is a good option for treating complex vertebral artery pathology with excellent immediate results and a lower complication rate compared with open repair. Long-term follow-up is necessary.

The most prevalent lesion of the vertebral artery is atherosclerotic plaque located at its origin from the subclavian artery,[1],[2] while atraumatic extracranial aneurysm of the vertebral artery origin is very rare. Extracranial vertebral artery aneurysms are very uncommon, with case reports implicating neck trauma as the most common underlying cause.[3] A variety of other rare etiologies have been reported, including blunt trauma, atherosclerosis, syphilis, rheumatoid arthritis, neurofibromatosis, various collagen vascular diseases, and vertebral fractures.[4] Small vertebral artery aneurysms can be incidental findings, but larger ones may manifest with neurologic symptoms and deficits corresponding to the size and location of the lesion.[5] Cerebrovascular incidents secondary to aneurysm thrombosis and rupture have also been reported.[6] There is no agreement about the best treatment strategy since both surgical and endovascular procedures are technically challenging.[7] Altering the hemodynamics of the vertebrobasilar circulation may lead to long-term complications that are difficult to predict. Here we report a case of a primary, extracranial aneurysm of the right vertebral artery causing embolic stroke of the posterior circulation.


 » Case Report Top


A 44-year-old man with no previous history of trauma presented with weakness in the right extremities. The physical examination revealed no obvious mass in his right supraclavicular region and no neurologic abnormalities. Cranial magnetic resonance imaging (MRI) demonstrated infarction of the pons segment [Figure 1]a. Computed tomography angiography (CTA) of the head and neck identified an aneurysm of the right proximal vertebral artery [Figure 1]b. After admission to our department, duplex ultrasound showed an aneurysm of the right V1 segment of the vertebral artery [Figure 1]i. Selective arteriography was performed under local anesthesia through a percutaneous femoral access, which confirmed a 12*14 mm saccular aneurysm involving the origin of the right vertebral artery [Figure 1]c, while the left vertebral artery was occluded [Figure 1]d. A balloon occlusion test (BOT) was not performed because the right vertebral artery was the only blood supply to the posterior circulation. Endovascular repair of the aneurysm was planned. The right subclavian artery was accessed via a 7F long sheath (Cook Medical, Bloomington, Ind), through which a 6*25 mm Viabahn stent (Gore Medical, Flagstaff, Ariz) was deployed at the origin of the right vertebral artery [Figure 1]f and [Figure 1]g. An immediate arteriogram showed complete exclusion of the aneurysm and patency of the intracranial vessels [Figure 1]h. The postinterventional course was uneventful. Postinterventional duplex ultrasound of the stented vertebral artery segment revealed no endoleak into the aneurysm sac [Figure 1]j. The patient was then discharged on oral double antiplatelet therapy for 3 months (clopidogrel 75 mg/day and aspirin 100 mg/day).[8] The 12-month follow-up CT scan demonstrated complete aneurysm exclusion and patency of the intracranial vessels [Figure 1].
Figure 1: (a): Cranial MRI demonstrating pons infarction. (b): CTA of the head and neck demonstrates an aneurysm of the right proximal vertebral artery. (c and d): Selective arteriography performed using a percutaneous femoral access demonstrates a 12*14mm saccular aneurysm involving the origin of the right vertebral artery (c) and occlusion of the left vertebral artery (d). Evaluation of the intracranial vessels supplied by the right vertebral artery reveals mild stenosis of the basilar artery (e). (f and g): A 6*25mm Viabahn stent (Gore Medical, Flagstaff, Ariz) was deployed at the origin of the right vertebral artery. The arteriogram obtained immediately after stent deployment shows complete exclusion of the aneurysm and patency of the intracranial vessels (h). (i): Preinterventional duplex ultrasound shows the diameter of the right proximal vertebral artery is significantly dilated as an aneurysm, and there is plaque on the walls of the aneurysm sac. (j): Postinterventional duplex ultrasound shows the stent in the aneurysm sac, and there is a hypoechoic band between the aneurysm walls and the stent. (k): The 12-month follow-up CT scan demonstrates complete aneurysm exclusion and patency of the intracranial vessels.


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 » Discussion Top


Approximately 25% of strokes originate from the vertebrobasilar system and most are due to specific vertebral artery (VA) pathology, including atherosclerosis, fibromuscular dysplasia, neurofibromatosis, arteritis, trauma, and dissection.[9] The majority of vertebral artery aneurysms involve the intracranial segment. Most extracranial vertebral aneurysms develop secondary to traumatic injury or are dissection-related pseudoaneurysms. A review of the literature[10] suggests that primary extracranial vertebral aneurysms tend to occur in patients with underlying connective tissue or other hereditary disorders, the most common being Ehlers-Danlos syndrome, Marfan's syndrome, and neurofibromatosis. True cervical vertebral artery aneurysms are rare, and primary aneurysms of the extracranial VA, as in the patient reported here, are very rare. Most extracranial VA aneurysms reported in the literature affect the V1 and V3 segments, usually the most mobile parts of the VA. In our patient, the aneurysm also occurred in the V1 segment. Published data indicate that both genders are affected and that the diagnosis is typically made in young to middle-aged adults.[1]

Presentation is variable. Some are asymptomatic with the aneurysms noted incidentally. Symptomatic patients can present with neck masses, dizziness, headaches, and neurologic deficits from cerebral ischemia or nerve compression.[11] Few cases of rupture have been reported.[12]

As the natural history is unknown, vertebral artery aneurysm management has been variable. In some reports, patients remained stable during observation, whereas, in others, the natural history included aneurysm growth, worsening of symptoms, and even stroke and death.[13] Several methods are available for extracranial vertebral aneurysm repair. The surgical approach includes primary ligation of the aneurysm, which was not an option in our patient due to occlusion of the contralateral vertebral artery. More complex surgical methods involve vertebral revascularization distal to the aneurysm prior to aneurysm exclusion. Surgical revascularization is associated with a 3-4% stroke and death rate, immediate graft thrombosis in 8% of cases, and a 2% risk of spinal injury.[14] Endovascular occlusion with detached balloon or coil embolization has also been reported,[15] but was also precluded in our patient because of contralateral vertebral artery occlusion. We preferred the covered stent for this case because it is a simple method to achieve aneurysm exclusion while preserving ipsilateral flow into the basilar artery when the contralateral vertebral artery is occluded. In our opinion, it is important to maintain ipsilateral flow even in patients with normal blood supply through the contralateral vertebral artery.

The possible disadvantages or limitations of the covered stent for primary vertebral artery aneurysm may be the need for oral double antiplatelet therapy for a longer period and the risk of endoleak due to stent malapposition if the vertebral artery is tortuous. Furthermore, wire, catheter, and stent manipulation inside the aneurysm can result in embolization or dissection.

In conclusion, primary extracranial vertebral artery aneurysms are rare, and their natural history is still unknown. For patients without mass compression symptoms, (the actual case), the endovascular approach with a covered stent offers good results and has fewer complications compared with open surgery and coil embolization. Long-term follow-up is necessary after placement of a covered stent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Morasch MD, Phade SV, Naughton P, Garcia-Toca M, Escobar G, Berguer R. Primary extracranial vertebral artery aneurysms. Ann Vasc Surg 2013;27:418-23.  Back to cited text no. 1
    
2.
Kao CL, Tsai KT, Chang JP. Large extracranial vertebral aneurysm with absent contralateral vertebral artery. Tex Heart Inst J 2003;30:134-6.  Back to cited text no. 2
    
3.
Matas R. Traumatisms and traumatic aneurysms of the vertebral artery and their surgical treatment, with the report of a cured case. Ann Surg 1893;18:477e516.  Back to cited text no. 3
    
4.
Rifkinson-Mann S, Laub J, Haimov M. Atraumatic extracranial vertebral artery aneurysm: Case report and review of the literature. J Vasc Surg 1986;4:288-93.  Back to cited text no. 4
    
5.
Hieda M, Toyota N, Kakizawa H, Hirai N, Tachikake T, Yahiro Y, et al. Endovascular therapy for massive haemothorax caused by ruptured extracranial vertebral artery aneurysm with neurofibromatosis Type 1. Br J Radiol 2007;80:e81-4.  Back to cited text no. 5
    
6.
Strambo D, Peruzzotti-Jametti L, Semerano A, Fanelli G, Simionato F, Chiesa R, et al. Treatment challenges of a primary vertebral artery aneurysm causing recurrent ischemic strokes. Case Rep Neurol Med 2017;2017:2571630.  Back to cited text no. 6
    
7.
Sultan S, Morasch M, Colgan MP, Madhavan P, Moore D, Shanik G. Operative and endovascular management of extracranial vertebral artery aneurysm in Ehlers-Danlos syndrome: A clinical dilemma--case report and literature review. Vasc Endovascular Surg 2002;36:389-92.  Back to cited text no. 7
    
8.
Fischer M, Schwabe C, Schulte KL. Value of the hemobahn/viabahn endoprosthesis in the treatment of long chronic lesions of the superficial femoral artery: 6 years of experience. J Endovasc Ther 2006;13:281-90.  Back to cited text no. 8
    
9.
Berguer R, Morasch M, Kline R. A review of 100 consecutive reconstructions of the distal vertebral artery for embolic and hemodynamic disease. J Vasc Surg 1998;27:852-9.  Back to cited text no. 9
    
10.
Buerger T, Lippert H, Meyer F, Halloul Z. Aneurysm of the vertebral artery near the atlas arch. J Cardiovasc Surg (Torino) 1999;40:387-9.  Back to cited text no. 10
    
11.
Stavrinou LC, Stranjalis G, Stavrinou PC, Bontozoglou N, Sakas DE. Extracranial vertebral artery aneurysm presenting as a chronic cervical mass lesion. Case Rep Med 2010;2010:938219.  Back to cited text no. 11
    
12.
Kollmann D, Kinstner C, Teleky K, Wressnegger A, Koppensteiner R, Huk I, et al. Successful treatment of a ruptured extracranial vertebral artery aneurysm with onyx instillation. Ann Vasc Surg 2016;36:290.e7-290.e10.  Back to cited text no. 12
    
13.
Kim HS, Choi CH, Lee TH, Kim SP. Fusiform aneurysm presenting with cervical radiculopathy in Ehlers-Danlos syndrome. J Korean Neurosurg Soc 2010;48:528-31.  Back to cited text no. 13
    
14.
Takahashi S, Katayama K, Tatsugawa T, Sueda T. A successful hybrid repair for vertebral arteriovenous fistula with extracranial vertebral artery aneurysm. Ann Vasc Surg 2015;29:126.e5-8.  Back to cited text no. 14
    
15.
Cohen JE, Gomori JM, Rajz G, Rosenthal G, El Hassan HA, Moscovici S, et al. Vertebral artery pseudoaneurysms secondary to blunt trauma: Endovascular management by means of neurostents and flow diverters. J Clin Neurosci 2016;32:77-82.  Back to cited text no. 15
    


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