A 67-year-old female with a medical history of hypertension and active smoking presented to the emergency department after experiencing a severe headache of sudden onset in the right side of her head. The patient had undergone elective screening colonoscopy the day prior. The morning following the colonoscopy procedure she woke up experiencing a right-sided headache associated with nausea, right-arm pain, right eye blurry vision, and slight fingertip numbness on her right side after which she decided to come to the hospital. She denied any recent trauma, fever, chills, or neck stiffness. On physical examination, she was neurologically intact.\nNoncontrast head CT demonstrated no acute intracranial pathology, specifically no evidence of subarachnoid hemorrhage. CT angiogram (CTA) demonstrated a 4.2 × 4.2 × 4.2 mm fusiform aneurysm arising off the superior cerebellar artery, approximately 1.5 cm distal to its origin off the basilar artery. The headache subsided the following day. Diagnostic cerebral angiogram was performed and redemonstrated the fusiform aneurysm, essentially unchanged in appearance when compared to the CTA []. The patient was started on dual antiplatelet agents consisting of clopidogrel 75 mg daily and aspirin 325 mg daily. One week later, the patient underwent successful Pipeline embolization of the aneurysm []. Briefly, a 6-Fr sheath was inserted into the right common femoral artery and a 6-Fr Benchmark guide catheter (penumbra) advanced over a diagnostic catheter and glide wire into the right vertebral artery. Through the guide catheter, a Phenom Plus distal access catheter was advanced over a Phenom microcatheter and Synchro-2 microwire into the proximal basilar artery. The microcatheter was then advanced over the microwire into the right superior cerebellar artery distal to the aneurysm. A 2.5 mm wide and 10 mm length Pipeline embolization device was then deployed along the fusiform aneurysm. Postdeployment angiogram demonstrated excellent apposition of the device to the parent vessel and evidence of some contrast stagnation within the aneurysm.\nThe patient was neurologically intact postoperatively and was discharged home on postoperative day 2. A cerebral angiogram performed 6 months later demonstrated resolution of the aneurysm with patency of the superior cerebellar artery []. The patient had no complaints and was neurologically intact.
A 56-year-old male patient came to the emergency room due to a right-sided occipital headache and vertigo, which suddenly began three days before the visit, and a symptom of tilting to the right, which began one day before the visit. There was no history of an external injury within the past one week. The patient did not have any underlying diseases, history of migraines, or risk factors for stroke, except for smoking. He also did not have a history of taking antiplatelet agents. When the patient visited the emergency room, his blood pressure was 160/100 mmHg, the pulse rate was 62/min, breathing rate was 19/min, and body temperature was 36.5 °C. The results of a neurological examination showed lateropulsion to the right side, hypoesthesia on the right side of the face, ataxia in the right upper and lower limbs, and the NIH stroke scale was 2. The results of serological studies and electrocardiography were normal.\nThe diagnosis was determined to be an acute ischemic stroke because the diffusion weighted imaging (DWI) of MRI revealed a high signal intensity area in the right lateral medulla. CT angiography (CTA) was taken first at 3 days after the symptom occurred. HR vw-MRI was taken a day after (at the 4th-day). The right PICA was not observed in the first CTA, and partial spontaneous recanalization was observed on the time-of-flight MR angiography (TOF-MRA), which was taken one day after. Moreover, the sagittal 3D T1 weighted HR vw-MRI showed a T1 hyperintense intramural hematoma in the right proximal PICA (Fig. ). However, a T2 weighted 3D curved MPR image revealed the luminal dilation and intimal flap in the right proximal PICA (Fig. ). The patient was diagnosed with spontaneous isolated PICA dissection on the basis of the neurological symptoms and imaging. He was treated with antiplatelet agents and the neurological symptoms of the patient improved during course of admission.