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Abstract
Introduction Sickle cell disease (SCD) is a clinical phenotype that presents a unique challenge to the interventonalist. Homozygous individuals express increased levels of surface adhesion markers and readily bind to activated endothelial cells, and evidence suggests platelets are likely chronically activated via persistent CD40L production. There are no formal guidelines regarding antiplatelet therapy in the short or long term for intracranial stent use in SCD. The authors describe a case of a dissecting bilobed/fusiform V4 segment aneurysm which was treated endovascularly with a pipeline embolization device (PED). The case was further atypical in that the patient’s vertebral arteries were extremely tortuous, and the anterior spinal artery arose from the segment of the vertebral artery bearing the aneurysm which precluded parent artery sacrifice. Considerations regarding antiplatelet therapy in this scenario are discussed.
Case Presentation 50-year-old right-handed woman was transported to our tertiary care center by ambulance after she experienced sudden onset 10/10 headache while at rest, accompanied by nausea and vomiting. Her past medical history was significant for sickle cell disease (HbSS) with previous vasoocclusive crises. Contrast-enhanced CT of the Circle of Willis demonstrated a fusiform/bilobed aneurysm of the vertebral artery, immediately distal to the posterior inferior cerebellar artery (PICA). 3D spin angiography revealed that the anterior spinal artery arose from the segment of the vertebral artery bearing the aneurysm. Despite severe tortuosity of the left vertebral artery, a pipeline emblolization device (PED) was successfully deployed into the V4 segment of the artery. Aneurysm persistently occluded at 2 year follow up.
Discussion Selecting a treatment method in SCD patients with a ruptured aneurysm is challenging and there are no clinical trials comparing treatment methods in this population. In the setting of this presumed dissecting vertebral aneurysm, we initially felt that endovascular vessel sacrifice would be preferred but due to origin of the anterior spinal artery a reconstructive approach with flow-diverter was selected. Optimal antiplatelet therapy in this situation is not known. Given presumed increased risk of thromboembolic complication this patient has been maintained on long term dual antiplatelet therapy. Management options are discussed.
Disclosures A. Dmytriw: None. T. Marotta: None. W. Montanera: None. M. Cusimano: None. A. Bharatha: None.