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.
A 42-year-old man with no past significant medical illness presented with headache. CT scan done showed subarachnoid hemorrhage (SAH) predominantly in the perimesencephalic cisterns []. Magnetic resonance imaging T1 gradient sequence also showed the hypointense signal suggestive of blood products in the perimesencephalic cisterns []. Fetal posterior cerebral arteries are seen on both the sides arising from the internal carotid artery [Figures and ]. DSA (digital subtraction angiogram) done subsequently revealed fusiform bulbous dilation involving both the cisternal and cortical segments of the left SCA []. Endovascular treatment in the form of parent artery occlusion was done under general anesthesia, with complete exclusion of the aneurysm from the circulation as seen on post-coiling angiogram []. Standard heparin protocol was followed and activated clotting time greater than 250 s was maintained during the procedure. Six-French (6F) Envoy (cordis) guiding catheter was placed in the distal vertebral artery. A combination of echelon-10 microcatheter (ev3) and transcend 0.014 microwire (Stryker) were used to access the aneurysms. Multiple Axium (ev3) coils were used to occlude the aneurysm. There were no intra- and periprocedural complications and patient was discharged on the 5th day after operation. The post-operative course was uneventful. The patient's neurological examination after 1 month was completely normal. Control angiogram done after 1 year showed stable occlusion of the aneurysm with endovascular coil in place [].