A 67-year-old female with a medical history of hypertension and active smoking presented to the emergency department after experiencing a severe headache of sudden onset in the right side of her head. The patient had undergone elective screening colonoscopy the day prior. The morning following the colonoscopy procedure she woke up experiencing a right-sided headache associated with nausea, right-arm pain, right eye blurry vision, and slight fingertip numbness on her right side after which she decided to come to the hospital. She denied any recent trauma, fever, chills, or neck stiffness. On physical examination, she was neurologically intact.\nNoncontrast head CT demonstrated no acute intracranial pathology, specifically no evidence of subarachnoid hemorrhage. CT angiogram (CTA) demonstrated a 4.2 × 4.2 × 4.2 mm fusiform aneurysm arising off the superior cerebellar artery, approximately 1.5 cm distal to its origin off the basilar artery. The headache subsided the following day. Diagnostic cerebral angiogram was performed and redemonstrated the fusiform aneurysm, essentially unchanged in appearance when compared to the CTA []. The patient was started on dual antiplatelet agents consisting of clopidogrel 75 mg daily and aspirin 325 mg daily. One week later, the patient underwent successful Pipeline embolization of the aneurysm []. Briefly, a 6-Fr sheath was inserted into the right common femoral artery and a 6-Fr Benchmark guide catheter (penumbra) advanced over a diagnostic catheter and glide wire into the right vertebral artery. Through the guide catheter, a Phenom Plus distal access catheter was advanced over a Phenom microcatheter and Synchro-2 microwire into the proximal basilar artery. The microcatheter was then advanced over the microwire into the right superior cerebellar artery distal to the aneurysm. A 2.5 mm wide and 10 mm length Pipeline embolization device was then deployed along the fusiform aneurysm. Postdeployment angiogram demonstrated excellent apposition of the device to the parent vessel and evidence of some contrast stagnation within the aneurysm.\nThe patient was neurologically intact postoperatively and was discharged home on postoperative day 2. A cerebral angiogram performed 6 months later demonstrated resolution of the aneurysm with patency of the superior cerebellar artery []. The patient had no complaints and was neurologically intact.
History & examination\nA 31-year-old African-American female with no significant medical history presented with a sudden onset of severe headaches that were highly suggestive of subarachnoid hemorrhage (SAH). The patient was initially evaluated in the emergency department where a neurological examination revealed no deficits.\nPathological findings\nA computed tomography (CT) scan revealed a SAH filling the pre-pontine, crural, ambient, and quadrigeminal cisterns more prominently on the left side of the brain, with mild hydrocephalus (Figure ). A CT-angiography (CTA) showed an enlarged vessel within the left ambient cistern. Digital subtraction angiography (DSA) also revealed the large and irregular appearance of the left SCA in the ambient cistern. No immediate intervention was undertaken.\nThe patient was admitted to the neurosurgical intensive care unit (ICU) and treatment was initiated with regular neurological examinations and daily transcranial-doppler (TCD) studies. The patient remained intact, with TCD values showing only moderate vasospasm. The patient did not require any treatment for the mild radiographic hydrocephalus. On Day 14, the patient underwent a repeat DSA which showed a persistent vasospasm in the distal basilar and bilateral posterior cerebral arteries. Three-dimensional (3-D) reformatting also demonstrated a dissecting fusiform SCA aneurysm in the lateral ponto-mesencephalic segment (Figure ). Due to the persistent vasospasm, no intervention was undertaken at that time as definitive treatment measures were being discussed in a multidisciplinary board meeting.\nEndovascular intervention\nOn Day 21, the patient underwent a successful placement of a low-profile visualized intraluminal support (LVIS Jr.) device (MicroVention, Tustin, CA) covering the fusiform aneurysm, which measured 3-mm wide and 18-mm in length. After premedication with aspirin and clopidogrel, a 7-Fr sheath was inserted into the common femoral artery and a 6-Fr guide catheter was inserted into the left vertebral artery. The left SCA was catheterized using the microcatheter and microguidewire. The LVIS Jr. device was then deployed successfully along the fusiform segment of the SCA without evidence of contrast extravasation. The treatment goal was to preserve the intraluminal flow with flow diversion from the aneurysm for reduction and eventual obliteration.\nPostoperative course\nAt the three-month follow-up, the patient had no complaint and was neurologically intact on examination. A CTA performed at that time showed the SCA patency proximal and distal to the stent without evidence of persistent dilatation or an aneurysm (Figure ). A formal catheter angiogram was deferred by the patient. At the 10-month follow-up, a DSA demonstrated the interval healing of the aneurysm with preserved vessel patency as well as mild distortion caused by the stent in the SCA (Figure ). The patient remained neurologically intact on examination with no complaints.