A 43-year-old Caucasian man was admitted to the emergency department of our hospital for headache associated with weakness of the left limbs. He had no medical history, he denied even slight trauma of the neck, and his only cardiovascular risk factor was tobacco smoking for 10 years. Neurological examination revealed verbal aphasia and left hemiparesis.\nDuring CT angiography (TK–64-row MDCT scanner, LightSpeed VCT, GE, Waukesha, WI) of the neck and head, segmental dissections of the right internal carotid artery (ICA) at the level of the cranial basis were discovered (Fig. a). The lumen of the ICA was decreased to 4 × 2.5 mm (60 % of normal flow). Cerebral CT showed a recent infarction involving the medial part of the right temporal lobe and deep structures of the right hemisphere including the thalamus, the genu and the posterior limb of the internal capsule (Fig. b).\nCT angiography of the neck and head also showed a duplication of the left vertebral artery (LVA) with two origins, both from the left subclavian artery (Figs. , ). The duplicated segments were fused at level of the C5–6 vertebrae into a single vertebral artery, which then entered the transverse foramen of C5 (Fig. ). All measurements were taken on an Advantage Workstation (GE).\nThe first LVA originated from the left subclavian artery at a distance of 7 mm from the aortic arch. It measured 2.9 and 2.8 mm in diameter at the points of origin and just before fusion, respectively (Fig. ). The course of the artery was 101 mm. The second LVA arose from the left subclavian artery 37 mm distal to the first (44 mm from the aortic arch). It measured 2.4 and 2.2 mm in diameter at the points of origin and just before fusion, respectively (Fig. ), and its course was 89 mm. Both vertebral arteries possessed a regular lumen. The diameter of the LVA after fusion was 3.3 mm (at level C5–6) (Fig. ).\nThe right VA arose as the first branch from the left subclavian artery, 43 mm from the aortic arch. Its course was normal. The diameters of the right VA were 4 mm at the points of origin and 3.8 mm at the C5–C6 vertebrae (Fig. ). Both thyrocervical trunks were seen to originate separately from the subclavian arteries.\nAdditionally, complementary but independent to CT angiography Doppler Sonography B-flow mode (Vivid 7 Pro, GE) of the vertebral arteries also revealed a duplicated LVA (Fig. ).\nAfter all procedures were completed, Ehlers–Danlos syndrome type IV was diagnosed.
A 69-year-old female patient presented with headache for 30 days. She had no other clinical manifestation or significant past medical history. There was no abnormal finding at the initial neurological examination.\nShe underwent cranial magnetic resonance image (MRI) with 3D time-of-flight (TOF) intracranial MRA and gadolinium-enhanced neck MRA, using 1.5T system (Signa Excite, GE Medical Systems, Milwaukee, WI, USA). Routine cranial MR images revealed no significant focal lesion in the brain parenchyma. 3D TOF intracranial MRA was also normal. Contrast-enhanced neck MRA demonstrated a duplication of the right VA with two origins from ipsilateral SCA before the origin of right internal thoracic artery (Fig. ). The two limbs of duplicated VA confined to proximal V1 segment, and converged to form one main trunk at the 3.6 cm distal from each orifice. The first and second limbs of duplicated V1 segment measured 2.8 and 2.6 mm in diameter at the points of origin, respectively. The distance between two limbs calculated 8.0 mm. The diameter of the common trunk of right VA was 3.8 mm at the point of reconstitution. On the left side, the VA arose from the left SCA and measured 4.1 mm in diameter. There was no other vascular abnormality in the major cervical arteries. The patient was managed conservatively and the patient’s clinical symptoms were relieved after 7 days.