David Andrew Wilkinson

Subarachnoid haemorrhage with bilateral intracranial vertebral artery dissecting aneurysms treated by staged endovascular stenting.

Bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid haemorrhage (SAH) are an exceedingly rare and deadly clinical dilemma. Prompt intervention in the case of unilateral VADAs is advocated to prevent rebleed; however, in the case of bilateral VADAs, the optimal therapeutic intervention is unclear. We describe the case of a patient presenting with SAH with bilateral VADAs treated by staged endovascular stenting. This led to resolution of the aneurysms with patency of both vertebral arteries. Stent-based therapy of the symptomatic aneurysm followed by staged stenting of the asymptomatic, contralateral aneurysm appears to be a viable treatment option. This method allows the ability to preserve flow in both vertebral arteries with minimal changes in flow characteristics that may threaten the contralateral, asymptomatic VADA, and appears to be the ideal treatment in these rare cases.

Delayed extrusion of embolic coils into the airway after embolization of an external carotid artery pseudoaneurysm

Carotid blowout syndrome (CBS) is a known devastating complication of head and neck surgery. The risk of developing CBS increases in the setting of radiation therapy, wound breakdown, or tumor recurrence. Traditionally, the treatment of choice for CBS is surgical ligation of the bleeding artery; however, recently, endovascular occlusion has become a more common option. If a pseudoaneurysm is present, treatment consists of trapping with endovascular coils or occlusion with a liquid embolic agent. Delayed migration of embolization coils into the airway causing acute respiratory distress is a rare occurrence. This report presents a case of a 57-year-old woman who presented to her otolaryngologist after experiencing an episode of acute respiratory distress which resolved when she expectorated embolization coil material from her tracheostomy tube. Three months prior to the episode she underwent coil embolization of an external carotid artery pseudoaneurysm for life-threatening hemorrhage.

Biology of Cerebral Aneurysm Formation, Growth, and Rupture

Abstract Cerebral aneurysm rupture leads to significant morbidity and mortality. The biological understanding of aneurysmal growth and rupture may lead to opportunities of preventing subarachnoid hemorrhage. This chapter is dedicated to presenting the current understanding of the biochemical and hemodynamic changes that allow aneurysmal growth and rupture. The role of turbulent flow leading to endothelial cellular damage and subsequent changes to the internal elastic lamina leading to myoproliferation is presented. Atherosclerosis has been integral to the development of ischemic stroke and we present its association to aneurysmal growth and rupture. The roles of proinflammatory markers, including matrix metalloproteinases and interleukin-1, are discussed as such markers are more common in patients with ruptured aneurysm as compared to asymptomatic aneurysms. Finally, we present risk factors of aneurysm rupture, including patient- and aneurysm-related factors as well as triggers for aneurysmal rupture.