A 28-year-old male without any previous medical history experienced right hemiplegia after a paroxysmal headache during sexual intercourse. He had a drowsy mentality and dysarthria. The National Institutes of Health Stroke Scale (NIHSS) score was 12. The brain magnetic resonance image (MRI) showed a pontine infarction (). The anterior-posterior view of his vertebral angiogram demonstrated an abrupt filling defect at the mid-basilar artery where the proximal margin of the defect was somewhat blurred and the distal was clearly circumscribed. On the lateral view, the abrupt filling defect was located at the anterior wall of the artery and the distal flow was compromised by a luminal stenosis (). These angiographic findings were highly suggestive of an anterior wall dissection of the basilar artery where the false lumen was filled up with mural hematoma.\nSince his neurological status had been deteriorating, a subsequent endovascular procedure was performed. After confirmation of the anatomical relationship between the true and false lumens, a microwire was navigated into the distal portion across the true lumen with extremely delicate handling to avoid incorrect cannulation into the false lumen. At the first trial of microwire navigation, it went into the intramural hematoma, and a clear resistance was noticed. Then, it was slightly pulled back and advanced again following the posterior wall of the diseased segment for a successful navigation. This maneuver confirmed presence of BAD. Then, a stent was deployed fully covering the lesion including some safety margins. After the stenting procedure, the distal flow was completely restored without residual false lumen (). A week later, he was able to walk unassisted. He discharged without any neurological deficits.
An 80-year-old male with severe constipation experienced a sudden headache during defecation. Shortly after, he visited local clinic for medication and abrupt left hemiplegia occurred. He was in a drowsy state and had dysarthria. The NIHSS score was 12. The brain MRI revealed a pontine infarction (). The T1-weighted image demonstrated a mural thickening with hyperintensity at the right anterior wall of the basilar artery (). On the vertebral angiogram, a contrast filling defect was found on the right anterior wall of the mid-basilar artery which was responsible for the luminal stenosis. Based on these radiological findings, a right anterior wall dissection of the basilar artery with mural hematoma was suspected. Similar to those angiographic findings on Case 1, the postero-superior border of the defect where the intimalflap might exist had a smooth and clear margin, and the inferior border where the mural hematoma and false lumen might be exposed had an irregular and unclear margin ().\nDuring the angiographic evaluation, his motor power dramatically improved to grade III. He had full recovery after conservative treatments including administration of low-molecular heparin and antiplatelet agent. Follow-up vertebral angiogram after two weeks demonstrated a fusiform aneurysmal dilatation with clearly visible intimal flap (). Since such aneurysmal formation caused by the enlargement of the false lumen has an extremely fragile wall and its rupture seemed to have a high mortality rate, an endovascular treatment was performed. Double stents were inserted into the true lumen fully covering the diseased segment. After the stenting, the false lumen was somewhat collapsed, but some residual false lumen was still visible (). Follow-up angiogram at two months after the initial ischemic onset demonstrated a complete healing of the dissection (). He remained in a symptom free state.