Ruptured giant aneurysms in the posterior circulation with poor grade subarachnoid haemorrhage (SAH) are associated with poor outcome. In this report four patients with ruptured giant vertebral artery aneurysms who presented acutely with World Federation of Neurosurgical Societies (WFNS) grade five SAH are reviewed. All 4 cases required intubation and ventilation on arrival. Brainstem reflexes were intact in all of them. Early endovascular parent artery coil occlusion was done in two cases. Two other cases were treated with early surgical proximal parent artery clip occlusion. Two cases required ventriculoperitoneal shunting. All cases achieved good recovery with full functional independent outcome at two years follow up. MR angiogram at two years documented resolution of aneurysms. In conclusion good outcome may be possible in some cases of ruptured giant vertebral artery aneurysms with WFNS grade five SAH.
Giant aneurysms are aneurysms larger than 25mm. In the Unruptured Cerebral Aneurysm Study of Japan only 0.5% of intracranial aneurysms are giants and only 1.8% of aneurysms are located in the vertebral artery [
Currently the management of giant aneurysms include reconstructive or deconstructive techniques. Surgical clipping of aneurysm sac or aneurysmorrhaphy eliminates the aneurysm sac from the circulation and preserve the flow in the parent artery [
Eighteen years old boy with no past medical history presented with sudden severe headache followed by rapidly declining conscious level. When he arrived at the hospital, he was totally unresponsive with Glasgow coma score (GCS) of 3. His pupils and brainstem reflexes were reactive. He had pink frothy pulmonary secretions and borderline oxygen saturation (signs of acute pulmonary oedema). He deteriorated rapidly and developed cardiac arrest. Cardiopulmonary resuscitation was instituted and he was intubated and ventilated. He also required inotropic support. Clinically there were no evidence of polycystic kidney disease, coarctation of aorta or connective tissue disorder. Urgent CT angiogram following hemodynamic stabilisation showed Fisher grade 4 SAH with clots in the posterior fossa and ventricles, giant left vertebral artery aneurysm with brainstem compression as well as hydrocephalus (
Postoperative CT 3 weeks post coil occlusion of the left vertebral artery showed reduction of mass effect in the posterior fossa (
Twenty-nine years old lady with no past medical history presented with sudden severe headache and deteriorating conscious level. Upon arrival she was flexing to painful stimulus with no eye opening or verbal response. Pupillary and brainstem reflexes were preserved. Urgent CT angiogram showed Fisher grade 4 SAH with posterior fossa clot, blood in fourth and lateral ventricles but no hydrocephalus. There was a right giant vertebral artery aneurysm with severe brainstem compression (
Fifty years old male with no past medical history was found to be unconscious. Upon arrival at the hospital he was flexing to painful stimulus with no eye opening or verbal response. Brainstem reflexes were preserved. He was intubated and ventilated for airway control. Urgent MRI showed a right vertebral artery giant aneurysm measuring 5 cm at its largest dimension with subarachnoid haemorrhage (
Twenty-seven years old male factory worker with no past medical history presented with sudden severe headache, vomiting and deteriorating conscious level. Upon arrival at the hospital he was extending to pain with no eye opening or verbal response. Brainstem reflexes were preserved. He was intubated and ventilated. Urgent CT scan showed Fisher grade 4 SAH with haematoma in the posterior fossa distorting the brainstem and intraventricular blood. There was no hydrocephalus. Cerebral angiography showed a large 35 mm giant aneurysm in the co-dominant left vertebral artery (
Poor grade SAH from ruptured giant aneurysms in the posterior fossa carries poor prognosis. Currently apart from cerebrospinal fluid diversion procedures to relief intracranial pressure, surgical or endovascular interventionists are hesitant to treat due to high risk of complications and poor outcome even when interventions were successful [
The treatment strategies for giant aneurysms today include reconstructive or deconstructive approaches, surgically or endovascularly [
Surgical reconstructive techniques include direct clipping of aneurysm neck or aneurysmorrhaphy. These two approaches are very challenging technically in the setting of severe brain swelling during the acute phase of acute SAH coupled with the severe mass effect of the aneurysm. High risk of haemorrhage during the dissection in between cranial nerves to achieve distal control during the acute phase of SAH made it an even harder uphill task. In fact, hypothermic circulatory arrest was advocated by some centres to allow for a safe period of bloodless field for the direct repair of these very difficult aneurysms [
Surgical proximal occlusion is simpler and carries less complications because there is no need for dissection beyond the proximal aneurysm neck when it is adopted as the definitive strategy. The main requirement is the presence of contralateral dominant or co-dominant vertebral artery (although bypass procedures such as superficial temporal artery to superior cerebellar artery is feasible it is usually not advocated in the acute settings). Cerebrospinal fluid diversion and decompressive craniectomy can be performed at the same time as proximal occlusion under the same general anaesthesia for surgery if indicated to improve cerebral perfusion. These are potentially even more helpful should the patient develop vasospasm subsequently. The important angiographic anatomy to pay attention to are the locations of the origin of PICA and ASA. Prior to surgery (if it is adopted as intervention of choice) it is also important to note the small percentage of extradural origin of PICA. Otherwise this important vessel may be damaged during exposure leading to lateral medullary syndrome. In Case 2 and 3, due to absence of ventriculomegaly lumbar drainage were carried out following craniectomy prior to dura opening (to avoid the risks of coning). Far lateral approach [
Endovascular deconstructive techniques include proximal coil occlusion, coiling of the aneurysm sac plus proximal coil occlusion as well as trapping with coils proximal and distal to the aneurysm [
Endovascular reconstructive techniques include stent assisted coiling or flow diversion with or without coils. Both require double antiplatelets. Sometimes for giant aneurysms of other intracranial locations where mass effect is not as critical as the posterior fossa early stage partial coiling followed by delayed stenting or flow diverter insertion after a period of antiplatelet loading have been performed [
In terms of aetiology for the aneurysms, these 4 cases did not have connective tissue disease, polycystic kidney or coarctation of aorta base on clinical history and examination. There were also no definitive double lumen sign or intimal flaps as proofs of intracranial dissection.
Since the publication of ISAT study results there has been a trend favouring endovascular compared to surgical approach for ruptured posterior circulation aneurysms [
It is also worth noting that endovascular parent artery occlusion can be performed after cerebrospinal fluid diversion procedures and / or craniectomy and cerebrospinal fluid diversion procedures. Conversely decompressive craniectomy can be performed following endovascular proximal occlusion. They are not mutually exclusive. In the same vein if surgical proximal clipping is not feasible or unsuccessful, endovascular proximal occlusion can be performed. If endovascular access is not feasible for one reason or another, surgical proximal clipping can be performed.
All 4 cases received early intensive care support and early endovascular or surgical intervention to prevent rebleeding. The youngest Case 1 returned to tertiary education after a year. The other three cases took two years to return to work. They were all 50 years old or below with no underlying medical morbidity. The ability of all of them to return to pre-morbid occupation was encouraging when the worse outcome was expected.
Proximal occlusion, endovascular or surgical, can be considered in young patients with ruptured giant vertebral artery aneurysms with WFNS grade five SAH and intact brainstem reflexes, when the collateral flow can be supported by contralateral vertebral artery.
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Axial CT at presentation showed hyperdense lesion (outlined by arrows) 49 mm in length which may represent haematoma or giant aneurysm. CT, computed tomography.
(A) Left vertebral artery angiogram AP view showed left vertebral artery giant aneurysm and PICA origin distal to aneurysm. (B) Left vertebral artery angiogram early arterial phase lateral view showed giant left vertebral artery aneurysm with PICA origin distal to it. AP, anteroposterior; PICA, posterior inferior cerebellar artery.
(A) Post coiling left vertebral artery angiogram AP view showed occlusion of the left vertebral artery with no filling of the aneurysm. (B) Left vertebral artery angiogram post coiling lateral view showed occlusion of the left vertebral artery with no filling of the aneurysm. AP, anteroposterior.
CT axial cut at the same level as
(A) CT angiogram axial view showed partially thrombosed right vertebral artery giant aneurysm with severe brainstem compression (arrows mark the outline of the aneurysm). (B) CT angiogram reconstructed AP view showed fusiform aneurysmal dilatation of the right intracranial vertebral artery with widening of the space between the two vertebral arteries due to mass effect of the partially thrombosed aneurysm. The two vertebral arteries are co-dominant. (C) CT angiogram reconstructed lateral view showed irregular fusiform aneurysmal dilatation of the intracranial right vertebral artery. CT, computed tomography; AP, anteroposterior.
MRA at two years follow up showed no filling of right vertebral artery and resolution of aneurysm. MRA, magnetic resonance angiography.
MRI coronal view showed a giant right vertebral artery aneurysm with severe brainstem compression. MRI, magnetic resonance imaging.
(A) Right vertebral artery angiogram lateral view showed partially thrombosed right vertebral artery giant aneurysm with PICA origin distal to it. (B) Right vertebral angiogram AP view showed partially thrombosed right vertebral artery giant aneurysm. PICA, posterior inferior cerebellar artery; AP, anteroposterior.
(A) Postoperative left vertebral artery angiogram lateral view showed no retrograde filling of the right vertebral artery giant aneurysm. Flow in distal right vertebral artery and right PICA was preserved. (B) Postoperative left vertebral artery angiogram AP view showed retrograde filling of distal right vertebral artery and right PICA but no retrograde filling of the original right vertebral artery giant aneurysm. PICA, posterior inferior cerebellar artery; AP, anteroposterior.
(A) Left vertebral artery angiogram AP view showing left vertebral artery giant aneurysm. (B) Left vertebral artery angiogram lateral view showing a giant left vertebral artery aneurysm distal to the PICA origin. AP, anteroposterior; PICA, posterior inferior cerebellar artery.
(A) Left vertebral artery angiogram AP view post coil occlusion showed no filling of the giant aneurysm. Flow in PICA was preserved. (B) Left vertebral artery angiogram lateral view post coil occlusion showed no filling of the giant aneurysm. Flow in PICA was preserved. AP, anteroposterior; PICA, posterior inferior cerebellar artery.