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37/F37/FSpontaneous SubarachnoidSpontaneous Subarachnoid

HemorrhageHemorrhage

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Episodic headache with blurring of Episodic headache with blurring of vision and giddiness- 4 monthsvision and giddiness- 4 months

Sudden onset of severe headacheSudden onset of severe headachefollowed by brief loc onfollowed by brief loc on20.11.2009.20.11.2009.

Headache lasted 4 days, recoveryHeadache lasted 4 days, recoverycompletecompleteNCCT head NormalNCCT head Normal

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Repeat episode of severe headache withRepeat episode of severe headache withloc for 15 mins on 27.11.2009.loc for 15 mins on 27.11.2009.

Headache persisted for 1 weekHeadache persisted for 1 weekNCCT head Fourth ventricular bleedNCCT head Fourth ventricular bleedwith ?subarachnoid hemorrhage inwith ?subarachnoid hemorrhage inbilateral CP angle cistern (R>L).bilateral CP angle cistern (R>L).

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ExaminationExamination

No neurological deficitNo neurological deficit

Neck rigidity presentNeck rigidity present

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ImagingImaging

CT angiography:CT angiography:

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CT angio : Right vertebral arteryCT angio : Right vertebral arteryfusiform aneurysm.fusiform aneurysm.

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IADSAIADSA

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RightV.A.

LeftV.A.

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RVA- AP

RVA-Lat

LVA-AP

LVA-Lat

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RICA LICA

PCOMPCOM

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Treatment OptionsTreatment Options

No interventionNo interventionSurgical clipping of aneurysmSurgical clipping of aneurysmStenting with coiling of aneurysmStenting with coiling of aneurysmOccluding the right vertebralOccluding the right vertebralarteryartery

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No InterventionNo Intervention

PROSPROS Extensive involvement.Extensive involvement.

Neurologically intactNeurologically intact

CONS:CONS: Risk of rebleeding, similar to any otherRisk of rebleeding, similar to any other

ruptured aneurysm.ruptured aneurysm.

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Surgical clippingSurgical clipping

PROSPROS Direct treatment.Direct treatment.

CONSCONS Extensive involvement of vertebralExtensive involvement of vertebral

arteryartery Difficult technically as all the wallsDifficult technically as all the walls

involved (blow out)involved (blow out)

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Right vertebral arteryRight vertebral artery

occlusionocclusionPROS:PROS: Flow reversal leading to obliterationFlow reversal leading to obliteration

of aneurysm.of aneurysm. Extensive involvement of vertebralExtensive involvement of vertebral

artery dealt with.artery dealt with.

CONS:CONS: Risk of ischemia.Risk of ischemia.

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Stenting with coiling of Stenting with coiling of aneurysmaneurysm

PROS:PROS: Direct treatment of the aneurysmDirect treatment of the aneurysm

CONS:CONS: Difficult to negotiate catheter throughDifficult to negotiate catheter through

the involved beaded segment withoutthe involved beaded segment withoutcausing dissection or bleeding.causing dissection or bleeding.

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ConcernsConcerns

Extensive involvement of bilateralExtensive involvement of bilateralvertebral and external carotid arteryvertebral and external carotid artery

branches.branches.Poor flow in posterior communicatingPoor flow in posterior communicatingarteryarteryLarge ruptured intracranial fusiformLarge ruptured intracranial fusiformaneurysm just near the right PICA.aneurysm just near the right PICA.If later on left vertebral artery involves,If later on left vertebral artery involves,chances of ischemia.chances of ischemia.

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RVA- AP (07.12.2009)

RVA- AP(30.11.2009)

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RVA -Lat

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LVA- AP

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RICA- AP LICA - AP

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Post Nimodipin

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Post occlusion

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Pre-occlusion

Post occlusion

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FibromuscularFibromuscularDysplasiaDysplasia

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FMD is an angiopathy that affects medium-FMD is an angiopathy that affects medium-sized arteries predominantly in youngsized arteries predominantly in youngwomen of childbearing age.women of childbearing age.FMD most commonly affects the renalFMD most commonly affects the renalarteries and can cause refractoryarteries and can cause refractoryrenovascular hypertension.renovascular hypertension.

Renal involvement occurs in 60-75%,Renal involvement occurs in 60-75%,

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Cephalic FMD: 95% have internalCephalic FMD: 95% have internalcarotid artery involvement and 12-carotid artery involvement and 12-

43% have vertebral artery43% have vertebral arteryinvolvement.involvement.Involvement of smaller bloodInvolvement of smaller bloodvessels, including intracranialvessels, including intracranialvessels, is rare.vessels, is rare.FMD is an important cause of FMD is an important cause of stroke in young adults.stroke in young adults.

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D/DD/D

MoyamoyaMoy amoya DiseaseDiseaseNeurosyphilisNeurosy philis

Takayasu Takaya su ArteritisArteritisVaricellaVaricella ZosterZosterVasculiticVasculitic NeuropathyNeuropa thy

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TreatmentTreatment

According to presentation andAccording to presentation andpathologypathology Stroke.Stroke. Dissection.Dissection. SAH with aneurysm.SAH with aneurysm.