Recanalization of a ruptured vertebral artery dissecting aneurysm after occlusion of the dilated segment only

BACKGROUND: Internal trapping in which the dissecting aneurysm is occluded represents reliable treatment to prevent rebleeding of ruptured vertebral artery (VA) dissecting aneurysms. Various methods of internal trapping are available, but which is most appropriate for preventing both recanalization of the VA and procedural complications is unclear. CASE DESCRIPTION: A 61-year-old male presented with subarachnoid hemorrhage caused by rupture of a left VA dissecting aneurysm. Only the dilated segment of the aneurysm was occluded by coil embolization. Sixteen days after embolization, angiography showed recanalization of the treated left VA with blood supplying the dilated segment of the aneurysm, which showed morphological change between just proximal to the coil mesh and just distal to a coil, and antegrade blood flow through this part. Pathological examination showed that the rupture site that had appeared to be the most dilated area on angiography was located just above the orifice of the entrance. However, we think that this case of ruptured aneurysm had an entrance into a pseudolumen that existed proximal to the dilated segment, with antegrade recanalization occurring through the pseudolumen with morphological change because of insufficient coil obliteration of the entrance in the first therapy. CONCLUSIONS: This case suggests that occlusion of both the proximal and dilated segments of a VA dissecting aneurysm will prevent recanalization, by ensuring that any entrance to a pseudolumen of the aneurysm is completely closed. Careful follow-up after internal trapping is important, since antegrade recanalization via a pseudolumen may occur in the acute stage.