Salvage strategies for spinal cord ischemia after flow diverter treatment of a vertebral artery–dissecting aneurysm: illustrative case

BACKGROUND Flow diverters (FDs) are increasingly used for vertebral artery–dissecting aneurysms (VADAs), but coverage of the anterior spinal artery (ASA) may cause spinal cord ischemia. OBSERVATIONS A 50-year-old man with an unruptured intracranial VADA underwent FD placement. The FD covered the origin of a large ASA adjacent to the aneurysm. Shortly after treatment, the patient developed quadriplegia and respiratory failure. Angiography showed preserved but delayed ASA flow without in-stent thrombosis. Recurrent neurological deterioration occurred 12 hours later. Suspecting ASA hypoperfusion, retrograde microcatheter-assisted stent massage was performed, successfully repositioning the FD away from the ASA ostium and improving ASA perfusion. MRI confirmed anterior spinal cord infarction. Following rehabilitation, the patient achieved substantial neurological recovery, with a modified Rankin Scale score of 1 at 6 months. Follow-up angiography demonstrated near-complete aneurysm occlusion and preserved ASA patency. LESSONS FD coverage of the ASA can result in spinal cord infarction, particularly when collateral circulation is limited. Careful evaluation of ASA anatomy and avoidance of ASA ostial coverage are critical during FD treatment of VADAs. https://thejns.org/doi/10.3171/CASE26617