• I Jonathan Pomeraniec, Panagiotis Mastorakos, Daniel Raper, and Min S Park.
• Department of Neurosurgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA.
• World Neurosurg. 2020 Nov 1; 143: 171-179.

BackgroundDissecting aneurysms of the posterior cerebral circulation can wield significant treatment challenges with devastating clinical outcomes. Despite an expanded therapeutic armamentarium, these vascular lesions remain relatively difficult to diagnose and portend high associated morbidity and mortality.MethodsA ruptured, fusiform, dissecting aneurysm of the mid V4 segment of the right vertebral artery (VA) distal to the posterior inferior cerebellar artery origin resulted in a Hunt and Hess grade 5, Fisher scale score 4 subarachnoid hemorrhage. The lesion incorporated 360 degrees of the vessel wall and extended across an area measuring 11 mm in length and 6.8 mm in width at maximum dimension. The vascular lesion was treated with 2 overlapping Pipeline Embolization Devices.ResultsDigital subtraction angiography demonstrated an origin of the right posterior inferior cerebellar artery mildly stenosed by the dissecting aneurysm. The left VA was markedly hypoplastic. After deployment of 2 overlapping Pipeline Embolization Devices, the aneurysm neck was well covered with appropriate positioning of the stent construct with good apposition to the vessel wall. There was contrast stasis within the aneurysm. The patient was managed with dual antiplatelet therapy. He demonstrated initial clinical and radiographic improvement. However, on the night of the second postprocedure day, the patient succumbed to rerupture of the aneurysm.ConclusionsThe literature posits that nonsaccular, fusiform, and dissecting aneurysms of the vertebrobasilar circulation can be occluded with consistency and success using flow diversion techniques. Endovascular treatment of a ruptured dissecting aneurysm of the VA is technically feasible and can be performed with or without parent artery occlusion. Outcomes following flow diversion of the posterior circulation may depend on the location of the dissection and viability of collateral circulation. In the present case, adequate coverage of the aneurysm did not portend a positive outcome.Copyright © 2020 Elsevier Inc. All rights reserved.

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