A case of vertebrobasilar fenestration malformation complicated by endovascular embolization of aneurysm complicated by spinal cord infarction

The patient, a 7-year-old woman, was transferred to Shanghai Tenth People's Hospital
from other places on January 8, 2015 due to sudden head and neck pain for 2 days.
When the patient slept 2 days before 2 days ago, there was no obvious cause of sudden severe pain and stiffness in the neck, and then the pain radiated to the head, without vomiting, numbness in the limbs and incontinence
.
Head CT examination was performed in the emergency department of the local hospital, and subarachnoid hemorrhage in front of the pontine was found (Figure 1), and conservative treatment such as hemostasis and analgesia was transferred to our hospital for further diagnosis and treatment
2 days.

Fig.
1 2 h CT after onset showed subarachnoid hemorrhage in the anterior pontine cistern

Physical examination on admission: clear consciousness, Glasgow Coma Scale (GCS) score of 15, neck rigidity, limbs and body depth of sensation, motor and other examinations are normal
.
Immediately after admission, whole brain DSA was performed, and it was found that the vertebrobasilar artery junction fenestration malformation was combined with a cystic aneurysm (Fig.
2, 3), the size was 1.
5 mm X 2.
5 mm, and the tumor neck ratio was <2.

Preoperatively, aspirin 200 mg and clopidogrel 300 mg were given as a load.

Fig.
2 Simultaneous angiography of bilateral vertebral arteries showed fenestration malformation at the vertebrobasilar artery junction and proximal aneurysm formation; Figure 3 three-dimensional DSA, showing that the aneurysm is located on the bridge artery proximal to the fenestration malformation

Under general anesthesia, bilateral femoral artery puncture is performed using Seldinger technique, in which a 6F vascular sheath is placed on the right side, a 5F vascular sheath is placed on the left side, and a 35mg heparin group is injected with systemic heparinization, and then half an additional dose is added every hour, and the active coagulation time during surgery is monitored and maintained for 250~300s
。 Use the 5F guide tube to superselect the left vertebral artery, and the F guide tube to superselect the right vertebral artery, First, the stent catheter is delivered to the left vertebral artery and the Enterprise 4.
5mmX22.
0mm (Cordis, USA) stent is released so that it covers the proximal end of the fenestration deformity, and the distal end is close to the beginning of the basilar artery; then a stent catheter is inserted into the right vertebral artery, and the SL-10 embolized microcatheter is super-selected into the aneurysm cavity under the guidance of the microguidewire, and a 2mmX40mm elastic ring is first filled (Microvention Corporation, USA, Figure 4), and it is found that the spring ring partially protrudes into the right vertebral artery, and the second Enterprise 4 is released through the right stent catheter After the .
5mmX22.
0mm stent was added, the second 2mmX40mm bullet ring (Microvention, USA) still found that the spring ring protruded into the right vertebral artery, so the third Enterprise 4.
5mmX22.
0mm stent was released in the right vertebral artery, showing that the spring ring was compressed into the tumor cavity, and then continued to fill two 2mmX40mm spring rings
.

Fig.
4 Protected by bilateral vertebral artery stent embolization of the aneurysm

After tamponade, the aneurysm was basically not developed, but considering that there was still blood flow in the left vertebral artery to impact the aneurysm, the fourth Enterprise 4.
5mmX22.
0mm stent
was released in the left vertebral artery.
Repeat angiography showed that the aneurysm was embolized densely, the stent was in a satisfactory position, completely covered the proximal pontine artery of the fenestration deformity where the neck of the aneurysm is located, and bilateral vertebrobasilar artery blood flow was unobstructed (Figs.
5, 6), and the operation
was completed.

Fig.
5 Immediate angiography after treatment showed that the aneurysm was not developed and bilateral vertebrobasilar artery blood flow was smooth; Figure 6 postoperative reconstruction shows that the 4 stents are well deployed, completely covering the aneurysm and the bridge artery where it is located, and the coil is confined to the aneurysm and aneurysmal artery

The patient was clearly conscious after surgery, but the physical examination found that the muscle strength of the left upper limb was grade 0, the muscle strength of the left lower limb was grade I, and the pathological signs were positive
.
Re-examination of head MRI showed scattered punctate ischemic foci in the skull (Figure 7), further examination of cervical spine MRI, found that the level of cervical 2~5 showed ischemic changes (Figure 8), and drug treatment such as expansion, anti-platelet aggregation, and anti-ischemic free radical damage was given
.
After 10 days, the patient's left limb muscle strength recovered to grade II, and he was discharged for further rehabilitation treatment
.
At local outpatient follow-up 2 months later, the proximal strength of the left upper limb was grade IV, the distal strength was grade III, and the strength of the left lower limb was grade
V.

Fig.
7 The MRI axis of the head on the second day after surgery showed multiple punctate ischemic foci in the right caudate nucleus and left occipital lobe.
Fig.
8 Lateral MRI of the spine on the second day after surgery showed spinal cord ischemia with edema changes at the 2~5 level of the neck