Introduction: The authors present a case of Hunt and Hess Grade 5 subarachnoid hemorrhage (SAH)) and hydrocephalus from a ruptured left intracranial vertebral artery fusiform dissecting aneurysm treated with a ventriculostomy and a Pipeline Embolization Device (PED) followed by ventriculoperitoneal (VP) shunt. We review the literature on the use of PED for ruptured fusiform intracranial vertebral artery dissecting aneurysms.

Methods: Case illustration: The patient is a 42-year-old Hispanic male presented to the Emergency Room with a Hunt and Hess Grade 5 SAH and acute hydrocephalus. Ventriculostomy was placed. A diagnostic cerebral angiogram showed a left vertebral artery fusiform dissecting cerebral aneurysm measuring about 10 mm x 8 mm x 6 mm distal to the origin of left posterior inferior cerebellar artery. We administered a loading dose of 300 mg of Plavix and 325 mg of Aspirin via nasal-gastric feeding tube about 8 hours prior to the intervention. On day 2 of SAH, we performed embolization of the aneurysm by placing a 2.75 mm diameter x 18 mm length PED. Intravenous Heparin bolus of 3000 units was administered to achieve Activated Coagulation Time of 200 prior to PED placement. No complication occurred. Patient was placed on daily Aspirin and Plavix.

Results: The patient was extubated on post-operative day 6. He underwent VP shunt insertion at one month. A follow up cerebral angiogram at 2 weeks showed complete occlusion of the aneurysm with no adverse change at 6 and 12 months. His Modified Rankin Scale score was 0 at 12 months.

Conclusions: Treatment of ruptured fusiform dissecting intracranial vertebral artery aneurysm associated with hydrocephalus is feasible and challenging. Review of literature on the use of PED in ruptured dissecting cerebral aneurysms is limited but suggest safety and feasibility in carefully selected group of patients.

Patient Care: By demonstrating via case illustration and review of the literature that PED may be used to treat acutely ruptured dissecting fusiform vertebral artery cerebral aneurysms

Learning Objectives: By the conclusion of this session, participants should be able to describe indications for the use of PED in acutely ruptured cerebral aneurysms and 2)Discuss challenges in the management of associated hydrocephalus and 3) Review the anti-platelet therapy in the peri-operative period

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