A 63-year-old woman presented with sudden onset vertigo and was diagnosed with an acute infarction in the left cerebellum on October 17, 2015. On the brain magnetic resonance imaging (MRI), an acute infarction was observed in the territory of the left superior cerebellar artery (SCA) (). Magnetic resonance angiography showed a mild irregularity in both proximal VAs and an occlusion in the left SCA (). For further evaluation, we performed a diagnostic cerebral angiography. The SCA was completely recanalized, and there was no definite abnormality in both VAs. Incidentally, we observed an unopacified streaming at the level of C5 during the selective catheter angiography of the left VA originated from the left subclavian artery (). And the medial limb of the left VA arising from the aortic arch could be found on the selective catheter angiography, which was not observed on the MRA. The dominant, lateral limb of the left VA was originated from the left subclavian artery () and the small, medial limb was originated directly from the aortic arch between the left common carotid artery and the left subclavian artery (). They joined at the transverse foramen of the fifth cervical vertebra.\nA right-to-left shunt was suspected on the transcranial doppler using an agitated saline solution with blood. A pulmonary arteriovenous malformation (AVM) in the right lung was detected by transesophageal echocardiography and chest computed tomography. With an elevated level of D-dimer with 421 ng/ml, the pulmonary AVM was suspected as a source of embolus causing an acute cerebellar infarction.
A 35-year-old man with left occipital pain underwent CT angiography. Reconstructed CT angiography showed a left duplicated VA originating from the left subclavian artery and aortic arch. Axial CT demonstrated that the medial limb of the duplicated VA was located anteriorly to the vertebral transverse foramen and medially to the CCA (). The patient’s symptom was relieved after conservative management.