Treatment Strategies of Subarachnoid Hemorrhage from Bilateral Vertebral Artery Dissection: A Case Report and Literature Review Focusing on the Availability of Stent Placement.

Abstract

Bilateral vertebral artery dissection (VAD) may result in subarachnoid hemorrhage (SAH). However, a variety of factors contribute to the difficulties with treating SAH. We report a case of bilateral VAD with SAH, as well as a literature review. A 32-year-old woman developed headache. Computed tomography demonstrated diffuse SAH, and 3-dimensional computed tomography indicated bilateral VAD. Her left vertebral artery was severely stenosed, and the basilar artery retrogradely flowed via the posterior communicating artery. Her bilateral VAD was trapped with the use of staged craniotomy. The postoperative course was uneventful for 13 days; however, severe neurologic deterioration remained in the area of the cerebral infarction, due to vasospasm of the internal carotid artery. This is the first report of hemorrhagic bilateral VAD treated with bilateral trapping and aggressive spasm treatment in the acute phase. However, the treatment was not successful. Because of the increasing use of stent therapy, there has been a shift toward this treatment choice. For cases in which stents cannot be used, treatment methods based on prestenting protocols are helpful. A literature review indicated that conservative treatment for 2 weeks, in which vasospasm and rebleeding are controlled, may be considered compared with acute-stage stent treatment. Following our literature review, in situations in which stents cannot be used, only the ruptured side should be trapped with strict blood pressure control and detailed radiological images should be observed for 2 weeks. In conclusion, patient selection is essential to subject the patient to open surgery in such cases.