A 52-year-old woman suddenly experienced vertigo and vomited while cleaning her bathtub at home and was subsequently transferred to our hospital by an ambulance. Head CT showed no abnormal findings, thus she was admitted under the suspicion of acute drug poisoning by a detergent. Although no abnormalities on a physical examination or in laboratory data were observed, her nausea and dizziness persisted. Neurologically, she presented only mild dizziness. MRI was then performed at 4 days after the onset, which showed an acute infarction in the left cerebellar hemisphere (Fig. ). The left VA was poorly visualized on MRA as compared to the right VA (Fig. ). In addition, the external diameter of the left VA on basiparallel anatomic scanning (BPAS) was narrowed, suggesting hypoplasia. The proximal portion of the left PICA was not visualized, and the adjacent distal portion appeared to be dilated on MRA (Fig. ). T1-VISTA showed a high-intensity signal area at the dilated portion (Fig. ). Conventional T1 image was obtained on admission and at 24 days after admission, but no high-intensity area was observed at both time points. Cardioembolic causes were excluded by echocardiography and 24-hour electrocardiography. According to these findings, Ischemic stroke of the cerebellum caused by dissection of the left PICA was diagnosed, and the administration of unfractionated heparin was started. Three days later, the dilated portion was enlarged on MRA, therefore, we discontinued unfractionated heparin administration. Since her blood pressure was not high, we even didn’t use antihypertensive treatment. At 8 days after the onset, cerebral angiography demonstrated the “pearl and string sign” at the proximal portion of the left PICA (Fig. ). Dilatation gradually normalized on MRA and the high-intensity signal area on T1-VISTA gradually reduced and disappeared at 4 months after the onset (Fig. ).
A 64-year-old man, who had a history of hypertension, presented with headache and vomiting. CT scan showed SAH in the superior cerebellar cisterns []. DSA done revealed a fusiform aneurysm of the distal SCA, predominantly involving the branch of the cortical segment [Figures and ]. Standard heparin protocol was followed and an activated clotting time greater than 250 s was maintained during the procedure. 5F Envoy (cordis) guiding catheter was inserted in the distal vertebral artery. The aneurysm was accessed with a combination of micro-catheter (echelon-10) and micro-wire (traxcess12). Meticulous pre-shaping of the micro-catheter according to the shape of the target aneurysm aided in proper positioning of the micro-catheter in the aneurysm which was subsequently packed densely with the platinum micro-coils. Post-procedure angiogram showed complete exclusion of the aneurysm along with the branch of the cortical segment and preservation of the flow in the superior cerebellar artery (SCA) []. There were no untoward events in the post-procedure hospital stay and patient was discharged after 1 week. No neurological deficit was seen during the clinical follow-up after 1 month. Control angiogram carried out after 1 year showed stable occlusion of the aneurysm with preservation of the ante-grade flow in the SCA [].