Endovascular trapping of a vertebral artery segment to control PICA origin tearing.
Iatrogenic perforation or rupture during aneurysm coiling can be difficult to manage and may lead to fatal bleeding. We describe a lifesaving technique of isolating the subarachnoid segment of the vertebral artery using two balloons to trap flow to a ruptured PICA aneurysm allowing time to coil the parent artery with the aneurysm.


METHODS
A 58-year-old woman presented with Hunt Hess Grade 3 subarachnoid hemorrhage due to a 3 mm left PICA aneurysm. During placement of the first coil, aneurysm perforation was noted. Despite conventional measures to manage the perforation (anticoagulation reversal, balloon inflation, placement of a second coil, and ventricular drain), contrast extravasation persisted after 45 minutes. A second balloon was positioned via the right vertebral artery at the right vertebrobasilar junction and inflated. The first balloon was pulled back, inflated, allowing trapping of the ruptured site. The aneurysm and adjacent vertebral segment were rapidly coiled to occlude the ruptured site under local flow arrest. The patient awoke with dysarthria, left-sided hemiparesis and dysphagia.


CONCLUSIONS
Trapping an arterial segment with two balloons may help in the management of PICA origin aneurysm perforation refractory to medical and current endovascular strategies. This technique, while potentially lifesaving, may engender ischemic complications.
Nguyen
Thanh N
TN
Department of Neurology, Neurosurgery, and Radiology, Boston University Medical Center, Boston, MA, USA.
Roy
Daniel
D
Guilbert
Francois
F
Raymond
Jean
J
Weill
Alain
A
D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging / Q000628:therapy*; D001488:Basilar Artery / Q000000981:diagnostic imaging; D002404:Catheterization; D002533:Cerebral Angiography; D004621:Embolization, Therapeutic; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000000981:diagnostic imaging / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007049:Iatrogenic Disease; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000628:therapy*; D014854:Lateral Medullary Syndrome / Q000175:diagnosis; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging / Q000628:therapy*; D014711:Vertebral Artery