Postpartum dissecting aneurysm of the posterior cerebral artery

Pregnancy as a Subgroup in the Pathophysiologic Classification of Spinal Aneurysms

BACKGROUND

Aneurysms of spinal arteries not associated with any known predisposing condition are referred to as isolated spinal aneurysms (SAs). In our series, an SA was found in 2 patients during the postpartum period. The goal of this study is to determine whether an occurrence of an SA may be related to puerperium.

METHODS

In a retrospective analysis of our consecutive series of 10 cases of SAs from 2008 to 2020, we identified 2 cases of SAs during puerperium. Patients' charts and imaging were reviewed, for potential predisposing factors.

RESULTS

In both cases, angiography showed fusiform aneurysms of the anterior SA with concomitant bilateral vertebral artery (VA) dissections. Serum vasculitis and inflammatory panel and genetic testing for collagen disorders were negative in both cases. Review of the literature showed that pregnancy is associated with an increased risk of arterial dissections in various locations and supports the hypothesis that hemodynamic and hormonal changes may play a role in the formation of SAs.

CONCLUSIONS

Pregnancy and peripartum state may be a distinct cause of the formation of SAs, possibly as a result of increased hemodynamic stress and hormonal changes that may alter the arterial wall. It would be appropriate to add pregnancy as a subgroup in the classification of SAs. In our series, both cases were associated with bilateral VA dissections; it is possible that the bilateral VA stenosis may have contributed to the formation of the SAs. It is important to recognize this possibility when considering the occlusion of a dissected VA.

Endovascular treatment of P3 segment of posterior cerebral artery aneurysm with stent and coils

Posterior cerebral artery (PCA) aneurysms are rare and usually arise from proximal portion of the artery. The distal location is even less frequent, and aneurysms in this location tend to be larger and dissecting. Although they can be treated by direct surgery, recently endovascular procedures have been preferred in some centers. We report a case of large aneurysm of the posterior cerebral artery in a 45-year-old female presenting with headache. An uneventful endovascular treatment was performed with stent and platinum coils achieving total occlusion of the aneurysm, and the patient had good recovery. The findings are compared to earlier reports and literature regarding the issue is discussed.

Awake endovascular coiling of a dissected intracranial aneurysm in a third-trimester twin pregnancy: A case report

RATIONALE

Subarachnoid hemorrhages (SAHs) from ruptured intracranial aneurysms are very rare during pregnancy. Management of ruptured intracranial aneurysms with SAH in pregnancy is often challenging because of the risks to the fetus and the mother. We present the first successful awake endovascular coiling of a dissected intracranial aneurysm in a third trimester twin pregnancy.

PATIENT CONCERNS

A 28 years' old pregnant woman was admitted at the obstetric department of our hospital on account of very severe headaches associated with nausea and vomiting.

DIAGNOSIS

Emergency obstetric ultrasound scan done confirmed 32 weeks' twin gestation, whereas magnetic resonance imaging established hemorrhage in the suprasellar cistern and the subarachnoid space. Magnetic resonance angiography revealed a dissected aneurysm in the ophthalmic segment of the left internal carotid artery.

INTERVENTIONS

Awake cerebral angiography as well as embolization of the aneurysm with coils was done via the transarterial route and the twins were delivered via caesarean section at 37 weeks' gestation.

OUTCOMES

Two years' follow-up indicated no complications and children as well as their mother are healthy.

LESIONS

Awake endovascular coiling was very beneficial in our case because we avoided general anesthesia and the use of osmotic diuretics which are potentially hazardous during pregnancy.

Ruptured Blister-like Aneurysm Arising From the Proximal Posterior Cerebral Artery

BACKGROUND

Blister-like aneurysms (BLAs) arise mostly at the supraclinoid internal carotid artery. We report a rare case of ruptured BLA arising at the P1 segment of the posterior cerebral artery (PCA).

CASE DESCRIPTION

A 34-year-old woman presented with disturbance of consciousness. Computed tomography (CT) of the head showed diffuse subarachnoid hemorrhage (SAH). A tiny bulge on the right PCA P1 segment was observed on initial CT angiography. The lesion enlarged little-by-little, with re-rupture occurring 10 days after initial hemorrhage. We diagnosed BLA arising at the P1 segment, and performed emergent endovascular parent artery occlusion (PAO) of the P1 segment. No infarction was observed in the territory of the PCA postoperatively.

CONCLUSIONS

Proximal PCA is a rare but possible location for BLA. When the cause of bleeding SAH cannot be identified, repeated radiologic assessments including posterior circulation should be performed. If perforators of the unaffected site supply the thalamus and midbrain bilaterally and an ipsilateral posterior communicating artery exists, PAO of P1 seems feasible as a treatment. Elective intervention is not recommended because of the characteristics of ruptured BLAs.

Dissecting aneurysms of the posterior cerebral artery - A retrospective review of imaging, angiographic characteristics, endovascular management and outcome

PURPOSE

To review management, clinical and imaging outcomes of dissecting posterior cerebral artery (PCA) aneurysms with emphasis on endovascular management in the form of parent vessel occlusion (PVO) at a tertiary care center.

METHODS

Thirty-six dissecting PCA aneurysms (19 ruptured) encountered at our center between January 2013 and November 2019 were reviewed for aneurysm location/size/presence of fetal PCA/management. Postprocedural imaging of patients who underwent endovascular intervention was reviewed for PCA territory infarcts and clinical records assessed for presence of neuro-deficits and outcome. None of the patients underwent a balloon test occlusion (BTO) prior to PVO.

RESULTS

The location of the aneurysms was as follows-P1 = 8/P1-P2 = 11/P2 = 5/P2-P3 = 10/P3 = 2. The mean size was 11.7x6.8 mm. Endovascular intervention was carried out in 20 patients in the form of PVO with coiling in 16 patients, coiling alone in 3 patients, and reconstruction of the left PCA with flow diverter deployment in one patient. Postprocedural PCA territory infarct was seen in 5 cases of PVO out of which 4 had a good functional recovery. Overall, 15/16 patients (93.7%) who underwent PVO had mRS ≤ 2 on follow-up. The single case with flow diverter also developed an infarct and had adverse outcome on follow up.

CONCLUSION

Among the various management strategies for dissecting PCA aneurysms, PVO is feasible and relatively safe even in absence of BTO in scenarios like critically ill patients with ruptured aneurysms, difficult access and financial constraints. Thromboembolic complications and antiplatelet therapy is a concern in reconstructive strategies.

Dissecting intracranial aneurysm in pregnancy: A rare association

We report a case of dissecting aneurysm of the right posterior cerebral artery presenting with sudden onset headache and altered behavior during labor. A 26-year-old P1001 with uncomplicated antenatal period, except history of headache off and on since 32 weeks of pregnancy, developed sudden onset headache and altered behavior during 3^rd stage of labor. She had vaginal delivery and a live born male baby was delivered with good Apgar score. The CT was suggestive of subarachnoid hemorrhage and DSA was suggestive of dissecting aneurysm of the right P2 segment with hypoplasia of right P1 segment and A1 segment of posterior and anterior cerebral artery, respectively. The patient was managed conservatively. At 4-month follow-up, the patient was doing well. We discuss about the rare association of a dissecting aneurysm and pregnancy, especially dissection of the posterior cerebral artery.

State-of-art in surgical treatment of dissecting posterior circulation intracranial aneurysms

Vertebrobasilar (VB) intracranial dissecting aneurysms (IDAs) pose difficult therapeutic issues and are especially among the most difficult to manage surgically. There are, however, some cases where selective aneurysm obliteration by endovascular approach is impossible or is associated with an unacceptable risk of morbidity. This is particularly true when the aneurysm is dissecting, giant, or has a large neck. In such cases, surgical treatment may be the only alternative. Optimal management of these lesions is therefore challenging and treatment decisions have to be made on a case-by-case basis. Ideal treatment should be a complete surgical excision of the lesion; however, this procedure might only be possible after distal and proximal vessel wall occlusion which might not be tolerated by the patient depending on the location of the aneurysm. Therefore, formulation of recommendations concerning the surgical strategy remains still difficult due to inconsistency of surgical outcomes. The literature describing surgical strategy of VB IDAs is varying in quality and content, and many studies deal with only a few patients. In the presented review, the authors summarize the current knowledge on the incidence, pathogenesis, clinical presentation, and diagnostic procedures with special emphasis on surgical treatment of IDAs in posterior circulation.

Postpartum vertebral artery dissection with posterior reversible encephalopathy syndrome

We diagnosed postpartum eclampsia with posterior reversible encephalopathy syndrome (PRES) in a 35-year-old woman who began experiencing headaches after delivery. Cervical MR angiography (MRA) suggested concomitant vertebral artery (VA) dissection. Antiplatelet therapy was not indicated. Each episode resolved spontaneously. The patient subsequently developed sudden onset of thunderclap headache. She experienced a tonicoclonic seizure in the outpatient clinic. On the basis of clinical course and MRI, we diagnosed postpartum eclampsia with PRES. Antiplatelet therapy was not indicated, as there were no signs of stroke. Antiepileptic and antihypertensive medicines were used for a short term to control seizure and blood pressure. Subsequent MRI 17 days after discharge showed resolution of the abnormal signals, but the intramural heme signals became apparent on the dissecting segment of VA. Subsequent MRI after 3 months indicated resolution of arterial dissection. To the best of our knowledge, this represents the third report of postpartum cervicocephalic artery dissection with PRES in the literature.

Endovascular treatment of a giant dissecting aneurysm of the posterior cerebral artery. A case report and literature review

We describe the case of a 60-year-old man who presented with a giant dissecting aneurysm of the left P2 segment. Intracranial dissecting aneurysms often occur in the vertebrobasilar system, but rarely involve the posterior cerebral artery (PCA). PCA aneurysms tend to have some peculiar features and therefore may be considered a separate entity, even from the vertebrobasilar aneurysms. The patient was treated by endovascular occlusion of both parent vessel and the aneurysm, and he tolerated the procedure well with a complete resolution of clinical deficit, following volume reduction of the aneurysm. This paper presents additional evidence to literature reports suggesting that endovascular parent artery occlusion with coils is an effective and well-tolerated treatment for distal PCA aneurysms. Our review contributes to collect data regarding the incidence of recurrence as a measure of long-term efficacy of this therapeutic approach.

Intracranial vertebrobasilar artery dissection associated with postpartum angiopathy

Background. Cervicocephalic arterial dissection (CCAD) is rare in the postpartum period. To our knowledge this is the first reported case of postpartum angiopathy (PPA) presenting with ischemic stroke due to intracranial arterial dissection. Case. A 41-year-old woman presented with blurred vision, headache, and generalized seizures 5 days after delivering twins. She was treated with magnesium for eclampsia. MRI identified multiple posterior circulation infarcts. Angiography identified a complex dissection extending from both intradural vertebral arteries, through the basilar artery, and into both posterior cerebral arteries. Multiple segments of arterial dilatation and narrowing consistent with PPA were present. Xenon enhanced CT (Xe-CT) showed reduced regional cerebral blood flow that is improved with elevation in blood pressure. Conclusion. Intracranial vertebrobasilar dissection causing stroke is a rare complication of pregnancy. Eclampsia and PPA may play a role in its pathogenesis. Blood pressure management may be tailored using quantitative blood flow studies, such as Xe-CT.