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.
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 [].