2017 Volume 45 Issue 2 Pages 140-147
The treatment strategy for ruptured bilateral vertebral artery dissection (VAD) is still controversial. We report two cases of ruptured bilateral VAD successfully treated with conservative and surgical treatments. Case 1 was that of a 48-year-old man who had a left occipital headache from 1 week before admission. On the day of onset, he had a severe sudden headache at the right occipital lobe followed by loss of consciousness. Head computed tomography (CT) on admission revealed subarachnoid hemorrhage (Fisher group 3), dominantly in the right prepontine and ambient cistern. Cerebral angiography revealed bilateral intracranial VAD. The right VA showed dilatation, and the left VA showed a string sign. We considered that the VAD ruptured on the right side, based on the CT image. As severe stenosis occurred in the left VA, we decided conservative therapy as a treatment strategy for case 1. The stenosis of the left VA was normalized 4 weeks after onset. The patient underwent ventriculoperitoneal (VP) shunt at the same period. The right VA dilatation was stable. Finally, the patient had no neurological deficit and was discharged 56 days after onset.
Case 2 was that of a 55-year-old woman who had a right occipital headache a week before admission. The headache worsened, and she was brought to our hospital in an ambulance. Head CT performed on admission revealed subarachnoid hemorrhage (Fisher group 3), dominantly in the right prepontine and sylvian fissure. Cerebral angiography revealed bilateral intracranial VAD. The right VA showed a pearl and string sign, and the left VA showed dilatation with wall irregularity. We considered that VAD ruptured on the right side based on the CT image. As right VA angiography revealed that the perfusion territory of the right anterior inferior cerebellar artery (AICA) covered the posterior inferior cerebellar artery (PICA), we performed proximal clipping of the right VA. The postoperative course was good, and the left VA stenosis was normalized at 1 month after onset. The patient underwent a VP shunt at the same period. He was discharged 60 days after onset without any neurological deficit.
We successfully treated two cases of ruptured bilateral VAD. For deciding on an appropriate strategy for this disorder, the dominancy of VA, the dissection type such as dilatation or stenosis, the collateral flow from the posterior communicating artery, and the perfusion territory of PICA and AICA should be considered in each case.
