A 63-year-old woman presented with sudden onset vertigo and was diagnosed with an acute infarction in the left cerebellum on October 17, 2015. On the brain magnetic resonance imaging (MRI), an acute infarction was observed in the territory of the left superior cerebellar artery (SCA) (). Magnetic resonance angiography showed a mild irregularity in both proximal VAs and an occlusion in the left SCA (). For further evaluation, we performed a diagnostic cerebral angiography. The SCA was completely recanalized, and there was no definite abnormality in both VAs. Incidentally, we observed an unopacified streaming at the level of C5 during the selective catheter angiography of the left VA originated from the left subclavian artery (). And the medial limb of the left VA arising from the aortic arch could be found on the selective catheter angiography, which was not observed on the MRA. The dominant, lateral limb of the left VA was originated from the left subclavian artery () and the small, medial limb was originated directly from the aortic arch between the left common carotid artery and the left subclavian artery (). They joined at the transverse foramen of the fifth cervical vertebra.\nA right-to-left shunt was suspected on the transcranial doppler using an agitated saline solution with blood. A pulmonary arteriovenous malformation (AVM) in the right lung was detected by transesophageal echocardiography and chest computed tomography. With an elevated level of D-dimer with 421 ng/ml, the pulmonary AVM was suspected as a source of embolus causing an acute cerebellar infarction.
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.