Case Study: Giant Vertebral Artery Aneurysm

At a Glance

  • UVA has two practitioners experienced in treating aneurysms utilizing either endovascular intervention or microsurgery.
  • Case study highlights the multiple approaches used to treat an aggressive, giant vertebral artery aneurysm.

Giant vertebral artery aneurysms are difficult to treat because they are located next to a lot of “high-stakes real estate,” according to UVA neurosurgeon Yashar Kalani, MD, PhD. “To treat these lesions surgically, you have to be able to manipulate the brain stem structures, the main arteries and cranial nerves without injuring them,” he says.

In some instances, endovascular treatments — strategic placement of stents or coils — are effective in treating this rare condition. When they’re not, patients like the one profiled below benefit from the breadth of expertise and resources available at UVA. “Most hospitals only have interventionalists who can do endovascular procedures or surgeons who can do microsurgery,” says Kalani. “We have two practitioners who can do both, so we offer balanced perspective and the full gamut of treatment options.”

Patient: 50-year-old male

Presented with: Swallowing difficulties, inability to walk

Evaluated by: UVA neurovascular team

Diagnosis: An incidentally identified giant left vertebral artery aneurysm, which was compressing his brain stem.

“The patient had been treated for the aneurysm by another practitioner,” says Kalani. “This initial treatment involved placing a flow-diverting stent that alters blood flow and allows the aneurysm wall to heal itself. Unfortunately, this patient’s aneurysm continued to grow despite placement of this device. He came to UVA in the summer of 2018 with symptoms of worsening compression of his brain stem, and he was rapidly deteriorating. He was no longer able to walk steadily and had swallowing difficulties.”

Endovascular Treatment: Placement of two stents

Given that the patient already had one flow-diverting stent placed across the neck of the aneurysm, many endovascular options were no longer available to the patient. “I took the patient back to the angiography suite and placed two additional flow-diverting stents, which decreased blood flow into the aneurysm,” says Kalani.

The patient’s symptoms were immediately improved after the procedure. He was discharged shortly after treatment and was counseled on smoking cessation.

“Unfortunately, the aneurysm again continued to grow and the patient presented in September 2018 with what was, at the time, a giant (greater than 2.5cm), partially thrombosed aneurysm of the vertebral artery,” says Kalani.

Surgical Treatment: Cardiac standstill induced by adenosine, followed by clip ligation of the aneurysm, aneurysmography and decompression of the brain stem.

“This aneurysm was difficult given its location and the fact that the brain stem was under significant compression. The patient was told that the treatment options carried a grave prognosis, but that the natural history of the aneurysm was aggressive and would most certainly lead to death,” says Kalani. “The patient at this time could no longer speak or control breathing and was intubated; he looked to me for a solution. I agreed to take on the case given the poor options available. However, I was forthcoming about the high risk of death or severe disability.”

Kalani determined the best option was complete occlusion of the aneurysm and decompression of the brain stem. Given the patient’s poor state of functioning, the team elected to perform a tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement prior to proceeding with treatment.

“After discussion with the patient, we took him to the OR where we induced cardiac arrest using the drug adenosine (administered by the anesthesiologist). This medication initiates 5-10 seconds of cardiac arrest. This short period of time is enough to stop blood flow to the brain, allow the aneurysm to become less stiff and for a clip to applied to occlude the aneurysm. I next opened the aneurysm and removed part of the clot to decompress the brain stem.”

Outcome: Stable and improving

The patient awoke from the procedure in stable condition. He had a prolonged ICU stay, but was ultimately discharged to a skilled nursing facility. Currently, he is still on (PEG) tube feeds. He has a tracheotomy with a speaking valve due to some difficulty clearing secretions, which are suctioned as needed. His strength is improving; he is able to sit without assistance and can stand for longer periods.