Severe Complications After Endovascular Trapping of Vertebral Artery Dissecting Aneurysm: Simultaneous Occurrence of Medullary and Cervical Spinal Cord Infarction

Endovascular trapping of vertebral artery dissecting aneurysm (VADA) can lead to ischemic complications, including medullary infarction due to obstruction of perforating arteries, and cervical spinal cord infarction caused by ischemia of spinal arteries branching from the affected vertebral artery (VA). This report describes a rare case of concomitant medullary and spinal cord infarction following internal trapping of ruptured VADA. A 47-year-old male presented with severe subarachnoid hemorrhage and neurological pulmonary edema, and a vertebral angiogram demonstrated VADA. A small-sized posterior inferior cerebellar artery (PICA) was found proximal to the affected vessel. The anterior spinal artery (ASA) branched distal to a dilated portion. Perforating arteries were insufficiently visualized due to image quality. Internal trapping was performed, and complete occlusion of VADA was achieved, preserving the origin of ASA. Postoperative magnetic resonance imaging (MRI) revealed ischemic lesions in the lateral medulla oblongata and upper cervical spinal cord. The patient presented with severe neurological symptoms, including lower cranial neuropathy due to medulla infarction, respiratory dysfunction, and tetraparesis due to cervical spinal cord infarction. The modified Rankin scale at three months was grade 5. Various factors, including perforating artery ischemia, unstable general condition, and insufficient antithrombotic therapy, were considered the cause. Therefore, evaluating the tiny perforating and spinal arteries branching from the VA should be especially considered to avoid these complications. Furthermore, advances in angiographic apparatus and workstations should provide a high-resolution radiological image and adequate treatment strategy.