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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.