Stent-assisted coil embolization of ruptured vertebral artery dissected aneurysm with severe stenosis of bilateral vertebral artery V4 segment by the Transmountain technique: a case report and review of the literatures

Stent-assisted coil embolization of ruptured vertebral artery dissected aneurysm with severe stenosis of bilateral vertebral artery V4 segment by the Transmountain technique: a case report and review of the literatures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Stent-assisted coil embolization of ruptured vertebral artery dissected aneurysm with severe stenosis of bilateral vertebral artery V4 segment by the Transmountain technique: a case report and review of the literatures Guangzhi Hao, Zijun Zhang, Yuwei Han, Yu Huan, Yushu Dong, Haiyang Zhao, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4761998/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A 46-year-old woman presented with acute head and neck pain for 10 hours. Head CT showed subarachnoid hemorrhage (SAH) and digital subtraction angiography (DSA) identified a ruptured dissected aneurysm of the right vertebral artery with severe artery stenosis. Moreover, an unruptured dissecting aneurysm and severe vascular stenosis were also found in the left vertebral artery. How to deal with ruptured bleeding aneurysm and prophylactically deal with contralateral unruptured dissecting aneurysm and the stenosis of the vertebral artery has become a thorny problem. By adopting the Transmountain technique, we used a single Enterprise-2 stent to cover the neck of the right ruptured vertebral artery dissection aneurysm and the severe stenosis of the distal vessel, while bypassing the vertebrobasilar artery junction to continue covering the severe stenosis and the unruptured dilated dissection of the contralateral vertebral artery. This new stent-assisted approach may provide a reference for clinicians in the treatment of complex dissection aneurysms. vertebral artery dissecting aneurysm subarachnoid hemorrhage stent-assisted coil embolization intravascular reconstruction Figures Figure 1 Figure 2 Figure 3 Introduction Vertebral artery dissecting aneurysm (VADA) are becoming the more common cause of spontaneous subarachnoid hemorrhage (SAH) in young and middle-aged people[ 1 ]. The rebleeding rate of ruptured intracranial VADA was high and the prognosis was very poor[ 2 ]. Previous studies have shown that the rate of rebleeding in VADA was as high as 70%, the rate of rebleeding within 24 hours was more than 50%, and the fatality rate was as high as 46%[ 3 , 4 ]. Intracranial vertebral artery had thin outer vascular membrane, few elastic fibers in the media, and lack of surrounding soft tissue support, which was more prone to bleeding[ 5 , 6 ]. Most of the bleeding was located in the posterior cranial fossa and the fourth ventricle, which could compress the brain stem, and was often accompanied by respiratory dysfunction and life-threatening[ 7 ]. Clinically, once the diagnosis of vertebral artery dissection aneurysm was clear, effective and active treatment should be taken as soon as possible to reduce the risk of aneurysm re-rupture, so as to reduce the mortality or disability rate. Here, we reported a novel treatment procedure for a particular complex case of ruptured vertebral artery dissecting aneurysm. By using a single Enterprise-2 stent and a small number of coils, we not only completely embolized the ruptured aneurysm and improved the ipsilateral severe stenosis, but also prophylactically alleviated the contralateral vertebral artery dissection and stenosis. Case report This study was approved by the Ethics Committee of Lingyuan Central Hospital. The patient and family members signed a written informed consent to the surgery and the publication of the case report, and all the imaging information is anonymized. A 46-year-old woman was admitted to the local hospital on May 14, 2024 with sudden severe headache and neck pain. The patient had a history of hypertension for 4 years and was treated with telmisartan orally. The patient denied the history of diabetes, heart disease, hepatitis, tuberculosis, mental illness, trauma and blood transfusion. Physical examination revealed lethargy, stiff neck, unresponsiveness and no paralysis. Preoperative head CT showed subarachnoid hemorrhage (Figure-1A), which was mainly concentrated in the pontine cistern and the cistern of pontocerebellar angle. Preoperative emergency CTA revealed an irregular-shaped aneurysm of the right vertebral artery with a severe stenosis (Figure-1B). After admission, the patient underwent further digital subtraction angiography (DSA) examination. Right vertebral arteriography revealed an irregular ruptured aneurysm in the V4 segment of the right vertebral artery with a size of about 5.5 mm x 4.0 mm and a neck of about 3.0 mm (Figure-1C). In addition, it was found that the right vertebral artery terminal was severely narrowed, with a stenosis degree of 80% (Figure-1C). The stenosis of the left vertebral artery terminal segment could reach 90%, and the local dilation of the left vertebral artery V4 segment indicated the presence of an unruptured dissecting aneurysm (Figure-1D). Oral antiplatelet therapy was given 2 hours before surgery with 300 mg of aspirin and clopidogrel respectively. The patient underwent endovascular interventional therapy on May 16, 2024. After successful general anesthesia, disinfection and sterile surgical sheets were routinely performed. The right femoral artery was punctured using the Seldinger technique and a 6F sheath was inserted. Then connect the Y-valve, tee and pressure injector. An 6F intermediate guiding catheter (Tethys®; Peijia Medical Technology, Suzhou, CNA) was placed through the Y valve and carefully advanced under fluoroscopy to reach the right truncus brachiocephalicus. Under the Roadmap, the intermediate guiding catheter was continued to be pushed to the V2 level of the right vertebral artery. A 205cm NeuroScout microguide wire (NeuroScout steerable guidewire; Codman, Massachusetts, USA) was used to carry stent microcatheter (Prowler Select Plus; Coman Corporation, Chaska, MN, USA) across the confluence of the vertebrobasilar artery into the V2 segment of left vertebral artery (Figure-2A). An Enterprise-2 stent (4.0mm x 39mm; Coman Corporation, Chaska, MN, USA) was slowly delivered through the stent microcatheter and carefully partly released after it was in place (Figure-2B). The NeuroScout microguide wire was then used to carry another microcatheter (Excelsior SL-10; Boston Scientific Corporation, Fremont, CA, USA) into the vertebral artery through the Y valve, and this SL-10 microcatheter was then superselected into the aneurysm under the guidance of Roadmap (Figure-2B). The head end of the single stent covered the proximal end of the left vertebral artery dilated dissection, and the tail end of the stent covered the proximal end of the right vertebral artery ruptured dissecting aneurysm, ensuring the full coverage of the neck of the right ruptured aneurysm, two severe stenosis of the vertebral artery and the left vertebral artery dissection. Four appropriately sized coils (2.0 mm x 8.0 cm x 2, 3.0 mm x 8.0cm x2; NRcoil™, Peijia Medical Technology, Suzhou, CNA) were gradually inserted into the aneurysm by SL-10 microcatheter until the aneurysm was radiographically completely occlusive (Figure-2C). Postoperative right vertebral arteriography showed that the ruptured dissected artery was densely embolized, and the vertebrobasilar artery flow was not affected. The right vertebral artery was clearly displayed, the stent was well attached to the vascular wall, and the stenosis at the end of the right vertebral artery was significantly relieved (Figure-2D). Anterior and lateral imaging of the left vertebral artery also showed that the stent was well attached to the wall, and additional distal stenosis was also improved (Figure-3A). The patient was awake after operation and speech and limb movement were normal. Head CT after operation showed no new hemorrhage or cerebral infarction (Figure-3B-D). Preoperative and postoperative 3D reconstruction showed that vascular stenosis was significantly improved, the single stent completely covered the dissection and stenosis of bilateral vertebral arteries, and basilar aneurysm blood flow was unobstructed (Figure-3E-F). Discussion The formation of intracranial vertebral artery dissection was associated with atherosclerosis[ 5 ]. The incidence of intracranial vertebral artery dissection was high in Asian population due to the high incidence of intracranial atherosclerosis[ 1 ]. Vertebral artery dissection was usually formed between the elastic membrane in the blood wall of the vertebral artery and the media[ 4 ]. The media and outer membrane of the intracranial vertebral artery was thin and after the formation of the dissection, it was easy to progress outwards, which at last forming VADAs and leading to SAH[ 8 ]. The early rebleeding rate of ruptured VADAs was very high, and active treatment is needed in the early stage of the disease[ 9 ]. Due to the disability and high mortality caused by surgical treatment in the acute stage, endovascular interventional therapy has gradually become the first choice of treatment[ 10 ]. A literature review identified five relevant articles describing VADA similar to ours (Table 1 )[ 11 – 15 ]. In two cases, the dissecting aneurysm was occlusioned and a vessel bypass surgery was performed, which resulted in mild ischemia. Transient thrombosis occurred in two cases of stent assisted aneurysm embolization. The last case, a pediatric patient, was treated conservatively. As the patient's condition was stable, regular follow-up was decided. Therefore, at present the main therapeutic method of VADA was endovascular interventional therapy, including occlusive therapy and endovascular reconstruction therapy[ 10 ]. Occlusive therapy should ensure sufficient blood flow compensation after occlusion, otherwise it may lead to the occurrence of large cerebral infarction[ 16 ]. The endovascular reconstruction of VADA mainly included single stent-assisted coil embolization, overlapping stent placement and flow diverter (FD) placement[ 17 ]. Table 1 Summary of cases of vertebral artery dissected aneurysm reported in the literature. Author, year Age,sex Symptom Maximum size (mm) Neck diameter (mm) Location Treatment Complications Results Follow-up (month) Clinical outcome Takahiro Yokoyama 2024 40, male mild headache Not described Not described left VA proximal clipping right vertebral artery expansion CO 6 Improved L. LIU, 2010 30, male headache and dizziness 9.7 5.3 Basilar Trunk SAT by Leo stent none CO 6 Improved Yukihiko Nakamura,2023 67, male impaired consciousness 12.6 6 left VA Coil embolization cerebral vasospasm CO 2 gradually recovered Mohammed.A. M. 2023 12, male diplopia, vomiting, ataxia, and severe headache Not described Not described left VA at the C3 and C4 levels Oral aspirin none Periodic review 2 Improved S.ANGIAFICO 2003 57, female acute excruciating headache Not described Not described V4 segment of the left VA Coil embolization ischemic stroke CO 6 gradually recovered CO complete occlusion, SAT stent-assisted technique, VA vertebral artery In this case, the condition of bilateral vertebral artery vascular was extremely special. Right vertebral artery dissection aneurysm was the focal point of hemorrhage, and the distal ipilateral vertebral artery was associated with severe stenosis. In addition, there were unruptured dissecting aneurysm and severe distal stenosis in the intracranial segment of the left vertebral artery. This complex case was discussed in detail in our joint treatment center before surgery. If overlapping stent placement or FD placement were used, this ruptured dissecting aneurysm could be resolved. However, the severe stenosis of the blood vessels at the end of the ipsilateral vertebral artery might hinder the release and adherence of the stent, thus affecting the blood flow of the vertebral artery or the puncture vessel and resulting in cerebral infarction. In addition, it has been reported that the application of FD placement had high requirements for perioperative antiplatelet therapy, which might increase the risk of re-rupture of dissecting aneurysm. The patient's family had limited financial resources and could not afford expensive blood flow guidance devices. Furthermore, the release of FD could not prophylactically address the problems of contralateral vertebral artery dissection and vessel stenosis. Therefore, the endovascular reconstruction treatment strategy in this case became a thorny issue. Creatively using the Transmountain technique, a single Enterprise-2 stent was released to simultaneously cover the neck of the ruptured dissecting aneurysm on the right, the unruptured dilated vascular dissecting on the left, and the two sites of severe vascular stenosis. In this case, the single stent played four important roles at the same time, including assisting the coil embolization of the wide-necked ruptured aneurysm, covering the left vertebral artery dissection, supporting the right vertebral artery terminal severe stenosis, and supporting the left vertebral artery terminal severe stenosis. Moreover, because Enterpreise-2 stent was a laser sculpting stent with low mesh metal coverage, the vertebrobasilar artery flow was not affected after vertebrobasilar junction was covered. Therefore, this single stent not only could assist the embolization of the ruptured aneurysm, but also could improve the severe stenosis of the ipsilateral distal blood vessel. Additionally, the 39mm Enterpreise-2 stent could also cover the dilatation of the contralateral vertebral artery preventively, preventing the dissection from becoming larger and causing rupture or narrowing of the vessel. All in all, a single interventional operation completely solved the multiple lesions of the patient's blood vessels, which greatly reducing the pain of the patient and saving huge medical costs for the patient who was not wealthy. Some medical centers reported that the application of overlapping stents could eliminate the vascular dissection better than the single stent-assisted coil embolization by reducing the mesh area of the stent[ 7 ]. It has also been reported that more and more treatment centers are using FD to treat dissection aneurysms[ 3 ]. The central idea of applying these two techniques was to improve the metal coverage of the interlayer, reduce the blood flow into the tumor, and promote the healing of the aneurysm[ 18 ]. However, there was no unified standard for the treatment of endovascular reconstruction in VADA, and the choice of treatment mainly depended on the location and morphology of the aneurysm and the relationship between the aneurysm and the collateral circulation vessels[ 19 ]. According to different cases, more accurate individual treatment strategies should be selected, and the complications and treatment costs should be reduced as much as possible. Conclusion Although vertebral artery dissection aneurysm with complex vascular conditions like this was rare, we creatively provided a novel endovascular treatment strategy. This method of stent release not only assisted the embolization of ruptured aneurysm, but also prevented the progression of unruptured vascular dissection and improved the severe stenosis of bilateral vertebral artery, which providing a new idea for the treatment of intracranial vertebral artery dissected aneurysm. Declarations Ethical Approval This report was reviewed and approved by Ethics Committee of the General Hospital of the PLA Northern Theater Command. All contents of WRITTEN INFORMED have been fully informed to the patient. Consent to publish This case was written after the patient's consent. Competing interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Authors' contributions Guangzhi Hao and Zijun Zhang determined the topic selection and wrote the main manuscript text. Yuwei Han and Yu Huan organized the data and prepared all the figures and table. Guobiao Liang and Haiyang Zhao reviewed all the figures and table. Yushu Dong reviewed the manuscript. Funding This project was sponsored by National Natural Science Foundation of China (82071481). Availability of data and materials All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author References Essibayi MA, Lanzino G, Keser Z. Endovascular treatments of intracranial vertebral and internal carotid arteries dissections: An interactive systematic review and meta-analysis. Interv Neuroradiol. 2024;30(1):22–30. Zhang Y, Tian Z, Zhu W, Liu J, Wang Y, Wang K, et al. Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10-year neurointerventional experience. Stroke Vasc Neurol. 2020;5(3):291–301. Oh HS, Bae JW, Hong CE, Kim KM, Yoo DH, Kang HS, et al. Stent-Assisted Coil Embolization Versus Flow-Diverting Stent in Unruptured Vertebral Artery Dissecting Aneurysms: Efficacy and Safety Comparison. Neurosurgery. 2023;93(1):120–27. Chaalala C, El Hage G, Gilbert V, Martin T, Iancu D, Labidi M, et al. Spontaneous intracranial vertebral artery dissections presenting with subarachnoid hemorrhage. Neurochirurgie. 2024;70(3):101526. Lee HJ, Choi JH, Kim BS, Shin YS. Symptomatic ischemic complications following endovascular treatment of vertebral artery dissecting aneurysms. Acta Neurochir (Wien). 2022;164(6):1645–51. Han J, Chen J, Tong X, Han M, Peng F, Niu H, et al. Morphological characteristics associated with ruptured intracranial vertebral artery dissecting aneurysms. J Neurointerv Surg. 2023;15(4):321–24. Durongwatana N, Sriamornrattanakul K, Wongsuriyanan S, Akharathammachote N. Microsurgical Treatment of Vertebral Artery Dissection: Surgical Strategies and Treatment Outcomes. World Neurosurg. 2022;159:e375-e88. Saw AE, McIntosh AS, Kountouris A. Vertebral artery dissection in sport: Expert opinion of mechanisms and risk-reduction strategies. J Clin Neurosci. 2019;68:28–32. Catapano JS, Ducruet AF, Cadigan MS, Farhadi DS, Majmundar N, Nguyen CL, et al. Endovascular treatment of vertebral artery dissecting aneurysms: a 20-year institutional experience. J Neurointerv Surg. 2022;14(3):257–61. Masuko Y, Shimizu N, Suzuki R, Suenaga J, Nagao K, Ohgaki F, et al. Reconstructive embolization for contralateral vertebral artery dissecting aneurysm that developed after internal trapping of ruptured vertebral artery dissection: A case report and literature review. Surg Neurol Int. 2022;13:124. Mangiafico S, Padolecchia R, Cellerini M, Puglioli M, Villa G, Nistri M. Rebleeding and ischemia after acute endovascular treatment of ruptured dissecting subarachnoid vertebral artery aneurysms. Interv Neuroradiol. 2003;9(2):205–12. Liu L, Jiang C, He H, Li Y, Wu Z. Delayed thrombosis of the basilar artery after stenting for a basilar trunk dissection aneurysm. A case report and review of the literature. Interv Neuroradiol. 2010;16(1):77–82. Nakamura Y, Takashima C, Nonaka T, Ohkubo T, Kawano T, Okura A, et al. Early recanalization and vasospasm after endovascular treatment in a case of ruptured vertebral artery dissecting aneurysm associated with COVID-19. Surg Neurol Int. 2023;14:324. Oshi MAM, Aljabri MF, Alotaibi S, Alzahrani Y, Alfaifi J, Abosabie SAS, et al. Vertebral artery dissection aneurysm in a pediatric patient: A rare case with unusual clinical manifestations, diagnostic, and management challenges. Medicine (Baltimore). 2023;102(47):e35906. Yokoyama T, Nomura S, Ishiguro T, Hodotsuka K, Kuwano A, Tanaka Y, et al. A case of bilateral vertebral artery dissection treated by bilateral surgical occlusion and low-flow bypass. Surg Neurol Int. 2024;15:121. Suyama Y, Nakahara I, Matsumoto S, Morioka J, Hasebe A, Tanabe J, et al. Early spontaneous occlusion of a vertebral artery dissecting aneurysm caused by subarachnoid hemorrhage: A case report. Radiol Case Rep. 2022;17(6):1977–81. Xu N, Meng H, Liu T, Feng Y, Qi Y, Wang H. Treatment of acute thromboembolic complication after stent-assisted coil embolization of ruptured intracranial aneurysm: a case report. Neuropsychiatr Dis Treat. 2019;15:69–74. Oya S, Yoshida S, Saito A, Shojima M, Yoshikawa G, Ota T, et al. The optimal management of ruptured basilar artery dissecting aneurysms: a case series and scoping review. Neurosurg Rev. 2022;45(5):3427–36. Chung J, Cheol Lim Y, Sam Shin Y. Endovascular Treatment of Intracranial Vertebral Artery Dissection. J Neuroendovasc Ther. 2021;15(5):265–80. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4761998","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":342133469,"identity":"dec7a3d5-7c14-41ef-a338-0e69855abc08","order_by":0,"name":"Guangzhi Hao","email":"","orcid":"","institution":"General Hospital of Northern Theater Command","correspondingAuthor":false,"prefix":"","firstName":"Guangzhi","middleName":"","lastName":"Hao","suffix":""},{"id":342133470,"identity":"66d1135b-64e7-48a8-ac64-28ac811bfd1f","order_by":1,"name":"Zijun Zhang","email":"","orcid":"","institution":"Lingyuan Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zijun","middleName":"","lastName":"Zhang","suffix":""},{"id":342133471,"identity":"89fbd7d2-9ac9-47ba-b34d-183692616517","order_by":2,"name":"Yuwei Han","email":"","orcid":"","institution":"General Hospital of Northern Theater Command","correspondingAuthor":false,"prefix":"","firstName":"Yuwei","middleName":"","lastName":"Han","suffix":""},{"id":342133472,"identity":"6e0aba96-f9ed-41fe-b59a-09f8a7426925","order_by":3,"name":"Yu Huan","email":"","orcid":"","institution":"General Hospital of Northern Theater Command","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Huan","suffix":""},{"id":342133473,"identity":"5ffac6bd-0e3c-4ccd-b1c7-a29dfb95d3ed","order_by":4,"name":"Yushu Dong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDCCAxAqgYHh8OEHHwxs7EjQwngszXBGQVoyCVqYzyhI83w4xNhASAff8d7Dr3nb6vIMjp1hMLYxOMDMwH746AZ8WiTPnEuz5m07XGxw5uyBxzkGd/gYeNLSbuDTYnAjx8yYt+1A4oYb5xKMcwyeMTNI8JgRo6UuccP9NwbSFgaHGRuI0GL8mLeNOXHDgTMG0gzEaJE8c8aMcc65w4kzDwADuccgLZmNkF/4jvcYf3hTVpfYdwAYlT/+2Njxsx8+hlcLELBJ8aBwCSgHAeaPP4hQNQpGwSgYBSMYAAC9aFc/RL65hQAAAABJRU5ErkJggg==","orcid":"","institution":"General Hospital of Northern Theater Command","correspondingAuthor":true,"prefix":"","firstName":"Yushu","middleName":"","lastName":"Dong","suffix":""},{"id":342133474,"identity":"18a674fc-aa8c-423b-8c86-feab9c44311c","order_by":5,"name":"Haiyang Zhao","email":"","orcid":"","institution":"Lingyuan Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haiyang","middleName":"","lastName":"Zhao","suffix":""},{"id":342133475,"identity":"8c925386-8267-4a9a-a9db-0d22fd4626d9","order_by":6,"name":"Guobiao Liang","email":"","orcid":"","institution":"General Hospital of Northern Theater Command","correspondingAuthor":false,"prefix":"","firstName":"Guobiao","middleName":"","lastName":"Liang","suffix":""}],"badges":[],"createdAt":"2024-07-18 10:51:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4761998/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4761998/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63290473,"identity":"0d7dd3e9-d90c-431c-ae11-d2dda3675d03","added_by":"auto","created_at":"2024-08-26 14:13:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1225364,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Preoperative computed tomography of the head showed subarachnoid hemorrhage. (B) CT angiography (CTA) suggested a right ruptured vertebral artery dissection aneurysm marked by “✱”. “\u003cstrong\u003e#\u003c/strong\u003e” indicated an unruptured dilated dissection of the left vertebral artery. Two arrows indicated severe stenosis at the ends of both vertebral arteries. (C) Digital subtraction angiography (DSA) identified a dissected aneurysm of the right vertebral artery with severe stenosis of the distal vessel. (D) DSA also showed an unruptured dissecting aneurysm and severe vascular stenosis in the left vertebral artery.\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-4761998/v1/837553d2e52b48f29724a411.png"},{"id":63291183,"identity":"f30e6194-3b20-4ffb-875c-23329b65975b","added_by":"auto","created_at":"2024-08-26 14:21:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1034387,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Intraoperative imaging showed the microguide wire carryied the stent microcatheter cross over the vertebrobasilar artery junction to reach the contralateral vertebral artery V4 segment. (B) The black arrow showed the Enterprise-2 stent was open and well attached to the vessel wall. The white arrow showed the SL-10 microcatheter entered the lumen of the dissecting aneurysm. (C) showed complete release of the stent after aneurysm embolization. This black arrow indicated that the end of the sent was fully open. (D) Digital subtraction angiography (DSA) examination was performed again after operation. The black arrow indicated that the aneurysm embolization was complete. The white arrow indicated a significant improvement in the stenosis of the distal vertebral artery.\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-4761998/v1/82d4a70e9877f6113948316a.png"},{"id":63290475,"identity":"53bd6d7e-e580-427c-8fde-a9001587f5ea","added_by":"auto","created_at":"2024-08-26 14:13:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1335024,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Postoperative angiography indicated that the distal stenosis of the contralateral vertebral artery had been relieved. (B) - (D) Postoperative head CT examination revealed that the stent crossed the V4 segment of the bilateral vertebral artery, and no new hemorrhage and cerebral infarction were found. (E) -(F) Preoperative and postoperative 3D reconstruction showed that vascular stenosis was significantly improved, the single stent completely covered the dissection and stenosis of bilateral vertebral arteries, and basilar aneurysm blood flow was unobstructed.\u003c/p\u003e","description":"","filename":"Fig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-4761998/v1/64affbe144e26571b53a80bf.png"},{"id":64083350,"identity":"d833e3cb-63be-4b28-940d-88697811d994","added_by":"auto","created_at":"2024-09-06 11:17:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5573277,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4761998/v1/071f311a-3f33-42e7-abac-07d7d031ed6a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Stent-assisted coil embolization of ruptured vertebral artery dissected aneurysm with severe stenosis of bilateral vertebral artery V4 segment by the Transmountain technique: a case report and review of the literatures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVertebral artery dissecting aneurysm (VADA) are becoming the more common cause of spontaneous subarachnoid hemorrhage (SAH) in young and middle-aged people[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The rebleeding rate of ruptured intracranial VADA was high and the prognosis was very poor[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Previous studies have shown that the rate of rebleeding in VADA was as high as 70%, the rate of rebleeding within 24 hours was more than 50%, and the fatality rate was as high as 46%[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Intracranial vertebral artery had thin outer vascular membrane, few elastic fibers in the media, and lack of surrounding soft tissue support, which was more prone to bleeding[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Most of the bleeding was located in the posterior cranial fossa and the fourth ventricle, which could compress the brain stem, and was often accompanied by respiratory dysfunction and life-threatening[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Clinically, once the diagnosis of vertebral artery dissection aneurysm was clear, effective and active treatment should be taken as soon as possible to reduce the risk of aneurysm re-rupture, so as to reduce the mortality or disability rate.\u003c/p\u003e \u003cp\u003eHere, we reported a novel treatment procedure for a particular complex case of ruptured vertebral artery dissecting aneurysm. By using a single Enterprise-2 stent and a small number of coils, we not only completely embolized the ruptured aneurysm and improved the ipsilateral severe stenosis, but also prophylactically alleviated the contralateral vertebral artery dissection and stenosis.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eThis study was approved by the Ethics Committee of Lingyuan Central Hospital. The patient and family members signed a written informed consent to the surgery and the publication of the case report, and all the imaging information is anonymized.\u003c/p\u003e \u003cp\u003eA 46-year-old woman was admitted to the local hospital on May 14, 2024 with sudden severe headache and neck pain. The patient had a history of hypertension for 4 years and was treated with telmisartan orally. The patient denied the history of diabetes, heart disease, hepatitis, tuberculosis, mental illness, trauma and blood transfusion. Physical examination revealed lethargy, stiff neck, unresponsiveness and no paralysis. Preoperative head CT showed subarachnoid hemorrhage (Figure-1A), which was mainly concentrated in the pontine cistern and the cistern of pontocerebellar angle. Preoperative emergency CTA revealed an irregular-shaped aneurysm of the right vertebral artery with a severe stenosis (Figure-1B). After admission, the patient underwent further digital subtraction angiography (DSA) examination. Right vertebral arteriography revealed an irregular ruptured aneurysm in the V4 segment of the right vertebral artery with a size of about 5.5 mm x 4.0 mm and a neck of about 3.0 mm (Figure-1C). In addition, it was found that the right vertebral artery terminal was severely narrowed, with a stenosis degree of 80% (Figure-1C). The stenosis of the left vertebral artery terminal segment could reach 90%, and the local dilation of the left vertebral artery V4 segment indicated the presence of an unruptured dissecting aneurysm (Figure-1D).\u003c/p\u003e \u003cp\u003eOral antiplatelet therapy was given 2 hours before surgery with 300 mg of aspirin and clopidogrel respectively. The patient underwent endovascular interventional therapy on May 16, 2024. After successful general anesthesia, disinfection and sterile surgical sheets were routinely performed. The right femoral artery was punctured using the Seldinger technique and a 6F sheath was inserted. Then connect the Y-valve, tee and pressure injector. An 6F intermediate guiding catheter (Tethys\u0026reg;; Peijia Medical Technology, Suzhou, CNA) was placed through the Y valve and carefully advanced under fluoroscopy to reach the right truncus brachiocephalicus. Under the Roadmap, the intermediate guiding catheter was continued to be pushed to the V2 level of the right vertebral artery. A 205cm NeuroScout microguide wire (NeuroScout steerable guidewire; Codman, Massachusetts, USA) was used to carry stent microcatheter (Prowler Select Plus; Coman Corporation, Chaska, MN, USA) across the confluence of the vertebrobasilar artery into the V2 segment of left vertebral artery (Figure-2A). An Enterprise-2 stent (4.0mm x 39mm; Coman Corporation, Chaska, MN, USA) was slowly delivered through the stent microcatheter and carefully partly released after it was in place (Figure-2B). The NeuroScout microguide wire was then used to carry another microcatheter (Excelsior SL-10; Boston Scientific Corporation, Fremont, CA, USA) into the vertebral artery through the Y valve, and this SL-10 microcatheter was then superselected into the aneurysm under the guidance of Roadmap (Figure-2B). The head end of the single stent covered the proximal end of the left vertebral artery dilated dissection, and the tail end of the stent covered the proximal end of the right vertebral artery ruptured dissecting aneurysm, ensuring the full coverage of the neck of the right ruptured aneurysm, two severe stenosis of the vertebral artery and the left vertebral artery dissection. Four appropriately sized coils (2.0 mm x 8.0 cm x 2, 3.0 mm x 8.0cm x2; NRcoil\u0026trade;, Peijia Medical Technology, Suzhou, CNA) were gradually inserted into the aneurysm by SL-10 microcatheter until the aneurysm was radiographically completely occlusive (Figure-2C). Postoperative right vertebral arteriography showed that the ruptured dissected artery was densely embolized, and the vertebrobasilar artery flow was not affected. The right vertebral artery was clearly displayed, the stent was well attached to the vascular wall, and the stenosis at the end of the right vertebral artery was significantly relieved (Figure-2D). Anterior and lateral imaging of the left vertebral artery also showed that the stent was well attached to the wall, and additional distal stenosis was also improved (Figure-3A). The patient was awake after operation and speech and limb movement were normal. Head CT after operation showed no new hemorrhage or cerebral infarction (Figure-3B-D). Preoperative and postoperative 3D reconstruction showed that vascular stenosis was significantly improved, the single stent completely covered the dissection and stenosis of bilateral vertebral arteries, and basilar aneurysm blood flow was unobstructed (Figure-3E-F).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe formation of intracranial vertebral artery dissection was associated with atherosclerosis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The incidence of intracranial vertebral artery dissection was high in Asian population due to the high incidence of intracranial atherosclerosis[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Vertebral artery dissection was usually formed between the elastic membrane in the blood wall of the vertebral artery and the media[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The media and outer membrane of the intracranial vertebral artery was thin and after the formation of the dissection, it was easy to progress outwards, which at last forming VADAs and leading to SAH[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The early rebleeding rate of ruptured VADAs was very high, and active treatment is needed in the early stage of the disease[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Due to the disability and high mortality caused by surgical treatment in the acute stage, endovascular interventional therapy has gradually become the first choice of treatment[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA literature review identified five relevant articles describing VADA similar to ours (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)[\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In two cases, the dissecting aneurysm was occlusioned and a vessel bypass surgery was performed, which resulted in mild ischemia. Transient thrombosis occurred in two cases of stent assisted aneurysm embolization. The last case, a pediatric patient, was treated conservatively. As the patient's condition was stable, regular follow-up was decided. Therefore, at present the main therapeutic method of VADA was endovascular interventional therapy, including occlusive therapy and endovascular reconstruction therapy[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Occlusive therapy should ensure sufficient blood flow compensation after occlusion, otherwise it may lead to the occurrence of large cerebral infarction[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The endovascular reconstruction of VADA mainly included single stent-assisted coil embolization, overlapping stent placement and flow diverter (FD) placement[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of cases of vertebral artery dissected aneurysm reported in the literature.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge,sex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSymptom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaximum size (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeck diameter (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003e(month)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eClinical outcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTakahiro Yokoyama 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emild headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot described\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot described\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eleft VA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eproximal \u003c/p\u003e \u003cp\u003eclipping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eright vertebral artery expansion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL. LIU, 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eheadache and dizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBasilar Trunk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSAT by Leo stent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYukihiko Nakamura,2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eimpaired \u003c/p\u003e \u003cp\u003econsciousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eleft VA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCoil embolization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ecerebral vasospasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003egradually recovered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMohammed.A. M. 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ediplopia, vomiting, ataxia, and severe headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot described\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot described\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eleft VA at the C3 and C4 levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOral aspirin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeriodic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS.ANGIAFICO\u003c/p\u003e \u003cp\u003e2003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57, female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eacute excruciating headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot described\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot described\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eV4 segment of the left VA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCoil embolization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eischemic \u003c/p\u003e \u003cp\u003estroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003egradually recovered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eCO complete occlusion, SAT stent-assisted technique, VA vertebral artery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn this case, the condition of bilateral vertebral artery vascular was extremely special. Right vertebral artery dissection aneurysm was the focal point of hemorrhage, and the distal ipilateral vertebral artery was associated with severe stenosis. In addition, there were unruptured dissecting aneurysm and severe distal stenosis in the intracranial segment of the left vertebral artery. This complex case was discussed in detail in our joint treatment center before surgery. If overlapping stent placement or FD placement were used, this ruptured dissecting aneurysm could be resolved. However, the severe stenosis of the blood vessels at the end of the ipsilateral vertebral artery might hinder the release and adherence of the stent, thus affecting the blood flow of the vertebral artery or the puncture vessel and resulting in cerebral infarction. In addition, it has been reported that the application of FD placement had high requirements for perioperative antiplatelet therapy, which might increase the risk of re-rupture of dissecting aneurysm. The patient's family had limited financial resources and could not afford expensive blood flow guidance devices. Furthermore, the release of FD could not prophylactically address the problems of contralateral vertebral artery dissection and vessel stenosis. Therefore, the endovascular reconstruction treatment strategy in this case became a thorny issue.\u003c/p\u003e \u003cp\u003eCreatively using the Transmountain technique, a single Enterprise-2 stent was released to simultaneously cover the neck of the ruptured dissecting aneurysm on the right, the unruptured dilated vascular dissecting on the left, and the two sites of severe vascular stenosis. In this case, the single stent played four important roles at the same time, including assisting the coil embolization of the wide-necked ruptured aneurysm, covering the left vertebral artery dissection, supporting the right vertebral artery terminal severe stenosis, and supporting the left vertebral artery terminal severe stenosis. Moreover, because Enterpreise-2 stent was a laser sculpting stent with low mesh metal coverage, the vertebrobasilar artery flow was not affected after vertebrobasilar junction was covered. Therefore, this single stent not only could assist the embolization of the ruptured aneurysm, but also could improve the severe stenosis of the ipsilateral distal blood vessel. Additionally, the 39mm Enterpreise-2 stent could also cover the dilatation of the contralateral vertebral artery preventively, preventing the dissection from becoming larger and causing rupture or narrowing of the vessel. All in all, a single interventional operation completely solved the multiple lesions of the patient's blood vessels, which greatly reducing the pain of the patient and saving huge medical costs for the patient who was not wealthy.\u003c/p\u003e \u003cp\u003eSome medical centers reported that the application of overlapping stents could eliminate the vascular dissection better than the single stent-assisted coil embolization by reducing the mesh area of the stent[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It has also been reported that more and more treatment centers are using FD to treat dissection aneurysms[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The central idea of applying these two techniques was to improve the metal coverage of the interlayer, reduce the blood flow into the tumor, and promote the healing of the aneurysm[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, there was no unified standard for the treatment of endovascular reconstruction in VADA, and the choice of treatment mainly depended on the location and morphology of the aneurysm and the relationship between the aneurysm and the collateral circulation vessels[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. According to different cases, more accurate individual treatment strategies should be selected, and the complications and treatment costs should be reduced as much as possible.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough vertebral artery dissection aneurysm with complex vascular conditions like this was rare, we creatively provided a novel endovascular treatment strategy. This method of stent release not only assisted the embolization of ruptured aneurysm, but also prevented the progression of unruptured vascular dissection and improved the severe stenosis of bilateral vertebral artery, which providing a new idea for the treatment of intracranial vertebral artery dissected aneurysm.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis report was reviewed and approved by Ethics Committee of the General Hospital of the PLA Northern Theater Command. All contents of WRITTEN INFORMED have been fully informed to the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u0026nbsp;\u003c/strong\u003eThis case was written after the patient\u0026apos;s consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGuangzhi Hao and Zijun Zhang determined the topic selection and wrote the main manuscript text. Yuwei Han and Yu Huan organized the data and prepared all the figures and table. Guobiao Liang and Haiyang Zhao reviewed all the figures and table. Yushu Dong reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eThis project was sponsored by National Natural Science Foundation of China (82071481).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEssibayi MA, Lanzino G, Keser Z. Endovascular treatments of intracranial vertebral and internal carotid arteries dissections: An interactive systematic review and meta-analysis. Interv Neuroradiol. 2024;30(1):22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Tian Z, Zhu W, Liu J, Wang Y, Wang K, et al. 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Acta Neurochir (Wien). 2022;164(6):1645\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan J, Chen J, Tong X, Han M, Peng F, Niu H, et al. Morphological characteristics associated with ruptured intracranial vertebral artery dissecting aneurysms. J Neurointerv Surg. 2023;15(4):321\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurongwatana N, Sriamornrattanakul K, Wongsuriyanan S, Akharathammachote N. Microsurgical Treatment of Vertebral Artery Dissection: Surgical Strategies and Treatment Outcomes. World Neurosurg. 2022;159:e375-e88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaw AE, McIntosh AS, Kountouris A. Vertebral artery dissection in sport: Expert opinion of mechanisms and risk-reduction strategies. J Clin Neurosci. 2019;68:28\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCatapano JS, Ducruet AF, Cadigan MS, Farhadi DS, Majmundar N, Nguyen CL, et al. Endovascular treatment of vertebral artery dissecting aneurysms: a 20-year institutional experience. J Neurointerv Surg. 2022;14(3):257\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasuko Y, Shimizu N, Suzuki R, Suenaga J, Nagao K, Ohgaki F, et al. Reconstructive embolization for contralateral vertebral artery dissecting aneurysm that developed after internal trapping of ruptured vertebral artery dissection: A case report and literature review. Surg Neurol Int. 2022;13:124.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMangiafico S, Padolecchia R, Cellerini M, Puglioli M, Villa G, Nistri M. Rebleeding and ischemia after acute endovascular treatment of ruptured dissecting subarachnoid vertebral artery aneurysms. Interv Neuroradiol. 2003;9(2):205\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu L, Jiang C, He H, Li Y, Wu Z. Delayed thrombosis of the basilar artery after stenting for a basilar trunk dissection aneurysm. A case report and review of the literature. Interv Neuroradiol. 2010;16(1):77\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura Y, Takashima C, Nonaka T, Ohkubo T, Kawano T, Okura A, et al. Early recanalization and vasospasm after endovascular treatment in a case of ruptured vertebral artery dissecting aneurysm associated with COVID-19. Surg Neurol Int. 2023;14:324.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOshi MAM, Aljabri MF, Alotaibi S, Alzahrani Y, Alfaifi J, Abosabie SAS, et al. Vertebral artery dissection aneurysm in a pediatric patient: A rare case with unusual clinical manifestations, diagnostic, and management challenges. Medicine (Baltimore). 2023;102(47):e35906.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYokoyama T, Nomura S, Ishiguro T, Hodotsuka K, Kuwano A, Tanaka Y, et al. A case of bilateral vertebral artery dissection treated by bilateral surgical occlusion and low-flow bypass. Surg Neurol Int. 2024;15:121.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuyama Y, Nakahara I, Matsumoto S, Morioka J, Hasebe A, Tanabe J, et al. Early spontaneous occlusion of a vertebral artery dissecting aneurysm caused by subarachnoid hemorrhage: A case report. Radiol Case Rep. 2022;17(6):1977\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu N, Meng H, Liu T, Feng Y, Qi Y, Wang H. Treatment of acute thromboembolic complication after stent-assisted coil embolization of ruptured intracranial aneurysm: a case report. Neuropsychiatr Dis Treat. 2019;15:69\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOya S, Yoshida S, Saito A, Shojima M, Yoshikawa G, Ota T, et al. The optimal management of ruptured basilar artery dissecting aneurysms: a case series and scoping review. Neurosurg Rev. 2022;45(5):3427\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung J, Cheol Lim Y, Sam Shin Y. Endovascular Treatment of Intracranial Vertebral Artery Dissection. J Neuroendovasc Ther. 2021;15(5):265\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"vertebral artery dissecting aneurysm, subarachnoid hemorrhage, stent-assisted coil embolization, intravascular reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-4761998/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4761998/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA 46-year-old woman presented with acute head and neck pain for 10 hours. Head CT showed subarachnoid hemorrhage (SAH) and digital subtraction angiography (DSA) identified a ruptured dissected aneurysm of the right vertebral artery with severe artery stenosis. Moreover, an unruptured dissecting aneurysm and severe vascular stenosis were also found in the left vertebral artery. How to deal with ruptured bleeding aneurysm and prophylactically deal with contralateral unruptured dissecting aneurysm and the stenosis of the vertebral artery has become a thorny problem. By adopting the Transmountain technique, we used a single Enterprise-2 stent to cover the neck of the right ruptured vertebral artery dissection aneurysm and the severe stenosis of the distal vessel, while bypassing the vertebrobasilar artery junction to continue covering the severe stenosis and the unruptured dilated dissection of the contralateral vertebral artery. This new stent-assisted approach may provide a reference for clinicians in the treatment of complex dissection aneurysms.\u003c/p\u003e","manuscriptTitle":"Stent-assisted coil embolization of ruptured vertebral artery dissected aneurysm with severe stenosis of bilateral vertebral artery V4 segment by the Transmountain technique: a case report and review of the literatures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 14:13:17","doi":"10.21203/rs.3.rs-4761998/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb6f8aed-cdc1-4a8d-b597-b024b486814d","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-06T11:09:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-26 14:13:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4761998","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4761998","identity":"rs-4761998","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}