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 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.