A 54-year-old man with chronic hypertension visited ED of a local hospital following the sudden onset of posterior neck pain and left-sided homonymous hemianopsia. A brain CT revealed a subcortical hemorrhage in the right occipital lobe []. He was diagnosed with a hypertensive intracerebral hemorrhage and admitted for several days to receive conservative management before he was discharged home. However, 2 weeks later, he experienced dizziness and visited our ED. A brain MRI (diffusion-weighted images) revealed a high-intensity signal in the left cerebellar hemisphere which corresponded to the area perfused by the left PICA []. The left PICA was poorly depicted on the brain MRA [] and a presumptive diagnosis of atherosclerotic PICA occlusion was made. However, CTA of the extracranial vessels obtained the next day revealed a tapered occlusion of the left VA inside the transverse foramen []. In addition, a thin-slice contrast-enhanced axial image at the C5 level showed a double-lumen sign [], establishing the diagnosis of an extracranial VA dissection. In retrospect, the initial hemorrhage in the right occipital lobe was not an arterial bleeding but was a hemorrhagic infarction secondary to a temporary embolic occlusion of the left posterior cerebral artery. Anticoagulation with warfarin was initiated, and the patient has not experienced a recurrent infarction for over a year.
A 64-year-old man, who had a history of hypertension, presented with headache and vomiting. CT scan showed SAH in the superior cerebellar cisterns []. DSA done revealed a fusiform aneurysm of the distal SCA, predominantly involving the branch of the cortical segment [Figures and ]. Standard heparin protocol was followed and an activated clotting time greater than 250 s was maintained during the procedure. 5F Envoy (cordis) guiding catheter was inserted in the distal vertebral artery. The aneurysm was accessed with a combination of micro-catheter (echelon-10) and micro-wire (traxcess12). Meticulous pre-shaping of the micro-catheter according to the shape of the target aneurysm aided in proper positioning of the micro-catheter in the aneurysm which was subsequently packed densely with the platinum micro-coils. Post-procedure angiogram showed complete exclusion of the aneurysm along with the branch of the cortical segment and preservation of the flow in the superior cerebellar artery (SCA) []. There were no untoward events in the post-procedure hospital stay and patient was discharged after 1 week. No neurological deficit was seen during the clinical follow-up after 1 month. Control angiogram carried out after 1 year showed stable occlusion of the aneurysm with preservation of the ante-grade flow in the SCA [].