Abstract
INTRODUCTION: Spinal cord infarction resulting from perforator occlusion and ischemia after Pipeline Embolization Devices (PEDs) deployment in the posterior circulation is a feared complication with devastating consequences. However, only 2 case reports described such occurrences, one involving the posterior spinal artery (PSA) after basilar artery aneurysm embolization and the other involving the anterior spinal artery (ASA) after embolization of a posterior inferior cerebellar artery (PICA) dissecting aneurysm. We present the first reported case of ASA syndrome after embolization of the V4 segment of the vertebral artery (VA), with a unique unilateral presentation. CASE DESCRIPTION: A 72‐year‐old right‐handed woman with a previous history of a stroke without any residual deficits underwent elective pipeline stent placement for an incidental, unruptured right V4 segment VA aneurysm originating at the origin of the right PICA (Figure 1A). The patient was premedicated with aspirin 81 mg daily and ticagrelor 90 mg twice daily for one week preoperatively. The initial procedure was uneventful, and the Pipeline Shield® (Medtronic) was deployed across the neck of the aneurysm. Several hours postoperatively, the patient developed acute onset right‐sided weakness affecting the right arm and leg; neurological examination revealed 4/5 strength in the right upper limb and 3/5 in the right lower limb. Per unit protocol was followed, and subsequent images were done, including CT head and CT‐angiogram of the head and neck, which were normal. Due to the new evolving symptoms, the patient was taken to the angiography suite where distal foreshortening of the stent was noted (Figure 1B). The decision was made to place a second stent to cover the aneurysm neck proximally and the procedure was performed successfully. Postoperatively, the patient had complete resolution of the symptoms and was transferred to the neurocritical intensive care unit. Later the same day, the patient experienced recurrent right‐sided weakness. Neurological examination revealed persistent hemiparesis without cranial nerve involvement. Repeat neuroimages revealed no acute intracranial bleeding with complete patency of the devices deployed. Despite continued dual antiplatelet therapy and blood pressure augmentation, her deficits remained unchanged. Subsequent MRI demonstrated a right anterolateral spinal cord infarct (Figure 1C), consistent with perforator‐related ischemia. CONCLUSION: To our knowledge, this case is the first reported ASA syndrome after flow diversion of a V4 vertebral artery aneurysm. Spinal cord infarction, although rare, should be recognized as a potential complication of posterior circulation PED deployment. Awareness of its possible unilateral presentation may facilitate timely diagnosis and management. [Image: see text]