A 32-year-old man was admitted to the emergency room with a history of sudden headaches, vomiting, and drowsiness. His past medical history showed arterial hypertension. On neurological examination, he was confused without localized neurological deficits. A computerized tomography (CT) scan showed a dense subarachnoid hemorrhage (SAH) with blood in the fourth ventricle. He underwent a digital angiography, which revealed a 6 mm fusiform SCA aneurysm without other signs of vascular dissection [].\nThe patient underwent surgery on the 15th post-hemorrhage day. He was positioned in park bench. A lumbar catheter was inserted and the cerebrospinal fluid (CSF) was drained to induce brain relaxation. A right subtemporal approach was performed, starting with a straight incision over the parietal branch of the STA. This artery was then dissected 10 cm from subcutaneous tissue under microscopic assistance. The temporal muscle was incised and a basal temporal craniotomy was performed. At that time, the lumbar drain was opened and 20 ml of CSF was drained. After a gentle lifting of the temporal lobe, the perimesencephalic cisterns were visualized and opened widely. The cerebellar tent was then incised. A fusiform dilatation of the SCA was observed between the anterior and lateral mesencephalopontine segments. The perforator arteries to brainstem were visualized proximal and distal to the aneurysm. A segment of the artery distal to the aneurysm that did not have perforator arteries was identified as the location for the anastomosis. The STA was then prepared for a terminolateral anastomosis. Temporary clips were positioned in the SCA segment and this artery was then opened and cleaned with heparin solution. Anastomosis was then performed in 40 min with 10-0 nylon single stitches. At the end of the procedure, the temporary clips were opened in a sequential manner. The patency of the anastomosis was confirmed by a micro-Doppler probe. Finally, aneurysm trapping was performed.\nThe patient had an unremarkable recovery and was discharged on postoperative day 7, with a prescription for 100 mg aspirin daily. The postoperative angiogram showed the patency of the bypass, with an excellent filling of the distal SCA segments from the bypass and total aneurysm exclusion [].
A 54-year-old man with chronic hypertension visited ED of a local hospital following the sudden onset of posterior neck pain and left-sided homonymous hemianopsia. A brain CT revealed a subcortical hemorrhage in the right occipital lobe []. He was diagnosed with a hypertensive intracerebral hemorrhage and admitted for several days to receive conservative management before he was discharged home. However, 2 weeks later, he experienced dizziness and visited our ED. A brain MRI (diffusion-weighted images) revealed a high-intensity signal in the left cerebellar hemisphere which corresponded to the area perfused by the left PICA []. The left PICA was poorly depicted on the brain MRA [] and a presumptive diagnosis of atherosclerotic PICA occlusion was made. However, CTA of the extracranial vessels obtained the next day revealed a tapered occlusion of the left VA inside the transverse foramen []. In addition, a thin-slice contrast-enhanced axial image at the C5 level showed a double-lumen sign [], establishing the diagnosis of an extracranial VA dissection. In retrospect, the initial hemorrhage in the right occipital lobe was not an arterial bleeding but was a hemorrhagic infarction secondary to a temporary embolic occlusion of the left posterior cerebral artery. Anticoagulation with warfarin was initiated, and the patient has not experienced a recurrent infarction for over a year.