This 37-year-old man with hypertension came to the Emergency room with complaints of sudden onset headache and right leg weakness after he stretched and yawned. Neurological examination showed alert mental state, frontal headache, and grade III weakness of the right leg. He had no remarkable past medical history, except nonspecific dizziness and headache since he was 25 years old. Head computed tomogram (CT) revealed scattered SAH at the left frontal convexities. A magnetic resonance (MR) images showed acute infarction at the rostrum of the left corpus callosum and double-lumen signal with high-signal hemorrhage (). Catheter angiogram showed multifocal dissections at the left carotid bulb and right vertebral artery with tiny aneurysm at the left proximal A2 (). His paresis seemed to be attributed to the infarction. After 3 days, dual antiplatelet agents were prescribed to prevent further ischemia and his weakness was gradually improved.\nHe underwent two more CT angiograms during the next months. Final angiogram revealed enlargement of the left A2 aneurysm and progression of focal stenosis along the ACA (). Endovascular intervention was performed under a general anesthesia by placing a 4.5×28 mm Enterprise stent (Cordis Neurovascular, Miami Lakes, FL, USA) through the A1 into the A2 segment, and deploying three Axium detachable helix coils (ev3 Inc., Irvine, CA, USA) into the aneurysm sac. Postoperative control angiogram revealed successful coil packing and flow preservation through the bilateral A2 segments (). Six months postoperatively, angiogram showed neither growth of aneurysms nor recurrence of stenosis (). He has no neurologic deficits and awaits another angiogram 12 months hereafter.
A 56-year-old male presented with deep stuporous consciousness with a Hunt and Hess grade of IV. Initial brain CT showed a thick SAH at the basal cistern, sylvian fissures, and anterior interhemispheric fissure (). Conventional cerebral angiography showed an azygous ACA, chronic total occlusion of the left proximal internal carotid artery (ICA), and a fusiform aneurysm on the right side wall of the A2 segment (). An arterial fenestration was also observed at the cavernous ICA. The aneurysm measured 6.25×2.86 mm in size on the 3-dimensional rotational angiogram with a neck size of 6.25 mm and height of 2.02 mm. The distal ACA flow remained patent without stenosis or occlusion.\nStent-assisted coil embolization of the azygous A2 dissecting aneurysm was performed under general anesthesia. A tiny remnant was left at the proximal portion (), however, follow-up angiography after two weeks showed complete obliteration of the aneurysm with preservation of the parent artery (). He showed improvement to drowsy mentality, but remained in a wheelchair-bound state.