A 67-year-old female with a medical history of hypertension and active smoking presented to the emergency department after experiencing a severe headache of sudden onset in the right side of her head. The patient had undergone elective screening colonoscopy the day prior. The morning following the colonoscopy procedure she woke up experiencing a right-sided headache associated with nausea, right-arm pain, right eye blurry vision, and slight fingertip numbness on her right side after which she decided to come to the hospital. She denied any recent trauma, fever, chills, or neck stiffness. On physical examination, she was neurologically intact.\nNoncontrast head CT demonstrated no acute intracranial pathology, specifically no evidence of subarachnoid hemorrhage. CT angiogram (CTA) demonstrated a 4.2 × 4.2 × 4.2 mm fusiform aneurysm arising off the superior cerebellar artery, approximately 1.5 cm distal to its origin off the basilar artery. The headache subsided the following day. Diagnostic cerebral angiogram was performed and redemonstrated the fusiform aneurysm, essentially unchanged in appearance when compared to the CTA []. The patient was started on dual antiplatelet agents consisting of clopidogrel 75 mg daily and aspirin 325 mg daily. One week later, the patient underwent successful Pipeline embolization of the aneurysm []. Briefly, a 6-Fr sheath was inserted into the right common femoral artery and a 6-Fr Benchmark guide catheter (penumbra) advanced over a diagnostic catheter and glide wire into the right vertebral artery. Through the guide catheter, a Phenom Plus distal access catheter was advanced over a Phenom microcatheter and Synchro-2 microwire into the proximal basilar artery. The microcatheter was then advanced over the microwire into the right superior cerebellar artery distal to the aneurysm. A 2.5 mm wide and 10 mm length Pipeline embolization device was then deployed along the fusiform aneurysm. Postdeployment angiogram demonstrated excellent apposition of the device to the parent vessel and evidence of some contrast stagnation within the aneurysm.\nThe patient was neurologically intact postoperatively and was discharged home on postoperative day 2. A cerebral angiogram performed 6 months later demonstrated resolution of the aneurysm with patency of the superior cerebellar artery []. The patient had no complaints and was neurologically intact.
A 38-year-old male patient came to the emergency room due to vertigo and vomiting that had started suddenly one day before the visit. The patient complained of a left-sided occipital headache that began two days before the visit. He had no history of trauma within 1 week prior to admission. The patient did not have any underlying diseases, history of migraines, or risk factors for stroke except for smoking and alcohol consumption. His blood pressure was 170/100 mmHg, the pulse rate was 70/min, breathing rate was 20/min, and body temperature was 36.5 °C. A neurological examination showed ataxia in the left upper extremity and the NIH stroke scale was 1. The results of serological studies and electrocardiography were normal.\nThe patient was determined to have an acute ischemic stroke because the DWI of MRI showed a high signal intensity area in the left PICA territory. CTA was taken at 2 days after the onset of a headache and at 1 day after the onset of neurological symptoms. Moreover, HR vw-MRI was taken at 6 days after the onset of a headache and at 5 days after the onset of neurological symptoms. Although the left PICA was not observed on the TOF-MRA, other vessels including the left vertebral artery were normal. An intraluminal high signal intensity and mild dilation of the left proximal PICA was revealed on routine 3D HR vw-MRI, but pathognomic signs of dissection was not seen. Curved MPR image reconstructed from 3D T2 weighted HR vw-MRI showed dilation and an intimal flap in the left PICA origin and post dilation stenosis in the left proximal PICA (D). (Fig. ). The patient was diagnosed with spontaneous isolated PICA dissection based on the neurological symptoms and imaging. The patient was treated with antiplatelet agents and discharged after his neurological symptoms improved.