Enlarging vertebrobasilar dolichoectasia with subarachnoid hemorrhage heralded by recurrent ischemia

Abstract

tation, elongation, and tortuosity of the vertebrobasilar arteries, and presenting symptoms result from ischemia or compression of the brainstem. Patients with VBDE rarely present with subarachnoid hemorrhage (SAH), and the predictors of rupture are unknown. We infer from the present case that progressive dilation may herald subsequent rupture. This 62-year-old man initially presented with acute vertigo, ataxia, vomiting, and left-sided weakness. Computerized tomography (CT) scanning and cerebral angiography revealed a 7-mm-diameter fusiform basilar artery aneurysm (Fig. 1 upper). Eighteen months later the patient presented with a sudden left-sided deafness, facial palsy, hypesthesia, and limb ataxia. Repeated neuroradiological studies revealed an increase in the size (diameter 1.2 2.3 cm) of the aneurysm (Fig. 1 lower) and acute infarction in the left anterior inferior cerebellar artery distribution. However, 5 days after readmission the patient suddenly became unresponsive due to SAH. The new onset of ischemic symptoms in a patient with an enlarging VBDE may be a clue to imminent rupture. Thrombus formation resulting from a recent critical enlargement may account for the sequence of events. The presentation of ischemic symptoms immediately before rupture has been previously reported.1–4 In three of these cases, the surgeons were aware of the entity for more than 1 year, and enlargement was suspected but not confirmed on neuroradiological imaging. We believe our case is the first in which such a sequence of events has been documented.