Here we present a case of a middle-aged man who presented to the hospital after being found down with subarachnoid hemorrhage.

As you can appreciate, he has a significant subarachnoid hemorrhage.

There was an extra focus of blood in the right lateral cerebellomedullary cistern. He also had dissections in the bilateral cervical ICAs and in the left V4 vertebral artery, but right V4 vertebral artery demonstrated the most significant vessel irregularity and the focus of blood around it, so it was presumed to the be the source of hemorrhage.

Here is a labeled version of the right vertebral artery injection

We decided to coil off the pseudoaneurysm given the high concern for re-hemorrhage. System: 6Fr Envoy DA + Echelon 10, 45 deg + Synchro 14 microwire with a mix of Axium and Barricade coils.

The post coiling angiogram demonstrated adequate occlusion of the right vertebral pseudoaneurysm.

The post coiling angiogram of the left vertebral artery shows adequate flow to the basilar artery. The left V4 pseudoaneurysm will have to be closely watched to ensure that it does not grow.