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.
A 70-year-old woman with hypertension, hyperlipidemia, and a history of smoking presented with a peripheral fusiform SCA aneurysm found incidentally during a routine MRI investigation due to “black out” symptoms. The aneurysm was located 2 cm from the SCA origin, and measured 7 mm in maximal diameter [Figure and ]. After a thorough discussion of treatment options, the patient elected to undergo a combined subtemporal, presigmoidal approach. On the lateral aspect of the brainstem, the aneurysm was exposed along with the parent artery and two major efferent branches. One of these branches, the largest one, was superiorly directed and a double, smaller branch, presented inferiorly around the aneurysm fundus. It was necessary during microsurgical dissection to detach the aneurysm dome from the tentorial undersurface as well as from the 4th cranial nerve. Multiple clips were used to reconstruct the aneurysm without intra-operative complication. Intra-operative angiogram confirmed reconstruction of the fusiform aneurysm with preservation of distal flow [Figure –]. The patient tolerated the procedure well and was extubated and returned to the intensive care unit in stable condition. She was discharged home on the fourth post-operative day without new deficit.