A 39 year-old male without past notable medical history was admitted with a sudden headache and neck stiffness. Brain computed tomography (CT) demonstrated evidence of Fisher Grade III subarachnoid hemorrhage (SAH) predominance of the pre-pontine, left ambient and quadrigeminal cistern (), and a fusiform aneurysm of a left distal SCA was revealed on the CT angiography (). Subsequent digital subtraction angiography (DSA) revealed the fusiform dilatation (12 mm length; 4.5 mm width) involving the ambient segment of the left distal SCA. The left SCA was duplicated ahead of the aneurysm and there was sufficient collateral circulation from the ipsilateral anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) (). The aneurysm was treated by endovascular occlusion of the aneurysm sac and the involved branch. Under general anesthesia an Excelsior SL-10 microcatheter was used to access the aneurysm. Seven detachable platinum coils were used to obliterate the lesion. Post-procedural angiography showed complete occlusion of the aneurysm sac and involved the SCA branch (). There was no immediate complication after embolization. Diffusion MRI was done 8 hours after embolization. MRI revealed scattered high signal change on the left posterior tegmentum, superior vermis, and superior part of the left cerebellum (). Left sixth nerve palsy occurred in the patient 1 day after EVT. The symptom completely recovered within 1 week of the post-procedural period. No neurological deficit was seen during the clinical 3-month follow-up.
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 [].