History is sudden onset severe headache. Declines angiography after CT and CTA (t=0). Two days later, extreme headache and mental status decline. CT / CTA show subarachnoid hemorrhage with growth of vertebral pseudoaneurysm. Note small proximal PICA aneurysm and prior right MCA clipping
What to do? Sacrifice is not a good idea — there is a large lateral medullary perforator originating from the dissected segment (no arrows, you should see it) Pipe into distal vert will jail the unruptured PICA aneurysm. Probably thats enough but who knows. The other option is to Pipe into the PICA. Its 1.2 mm — at the margin of what is possible. Not too tortuous, but catheterizing beyond the aneurysm might be tricky, as well as advancing the Phenom 27. There will be a lot of vessel displacement. Is it worth it?
That is what we did. The Phenom would not advance over an 014. An 008 buddy wire could not be advanced beyond the PICA aneurysm. Aristotle 24 had some trouble getting beyond the aneurysm, but once it did, Phenom advanced smoothly
Pipe Shield 2.5×18, 2.5×18, 2.5×14. Double coverage of the larger fusiform segment and double coverage of the PICA aneurysm.
Arrows point to a portion of the dissection not directly apposed by the Pipe construct. Another consequence of going for PICA instead of the vert.
Do you see subtle malapposition between the first and second PED? It is inconsequential and balloon angioplasty made it better — but still good to know
A Youtube video time laps of the case — can be useful for some details
