An 80-year-old male with severe constipation experienced a sudden headache during defecation. Shortly after, he visited local clinic for medication and abrupt left hemiplegia occurred. He was in a drowsy state and had dysarthria. The NIHSS score was 12. The brain MRI revealed a pontine infarction (). The T1-weighted image demonstrated a mural thickening with hyperintensity at the right anterior wall of the basilar artery (). On the vertebral angiogram, a contrast filling defect was found on the right anterior wall of the mid-basilar artery which was responsible for the luminal stenosis. Based on these radiological findings, a right anterior wall dissection of the basilar artery with mural hematoma was suspected. Similar to those angiographic findings on Case 1, the postero-superior border of the defect where the intimalflap might exist had a smooth and clear margin, and the inferior border where the mural hematoma and false lumen might be exposed had an irregular and unclear margin ().\nDuring the angiographic evaluation, his motor power dramatically improved to grade III. He had full recovery after conservative treatments including administration of low-molecular heparin and antiplatelet agent. Follow-up vertebral angiogram after two weeks demonstrated a fusiform aneurysmal dilatation with clearly visible intimal flap (). Since such aneurysmal formation caused by the enlargement of the false lumen has an extremely fragile wall and its rupture seemed to have a high mortality rate, an endovascular treatment was performed. Double stents were inserted into the true lumen fully covering the diseased segment. After the stenting, the false lumen was somewhat collapsed, but some residual false lumen was still visible (). Follow-up angiogram at two months after the initial ischemic onset demonstrated a complete healing of the dissection (). He remained in a symptom free state.
Patient, 45-years-old female, was admitted in hospital on the next day after intracranial hemorrhage.\nIt is known that the onset of the disease was with a sudden headache, pain in cervico-occipital localization and rise of the arterial blood pressure up to 220 mm Hg. On admission to hospital a condition was critical, 11 Glasgow Coma Scale, Hunt-Hess 3 meningeal signs. The pupils are equal. Oculomotor dysfunction and visible paresis are not detected. The Babinsky signs on both sides.\nData on the previous infections, craniocerebral injuries and systemic connective tissue disorders are not detected.\nTranscranial Doppler verified the rise of cerebral blood flow up to 220 cm/s.\nBrain computed tomography (CT) scan and CT-angiography revealed the right sided FA on the A1-segment of ACA, basal SAH, intracerebral hematoma in the mediobasal frontal lobe and in the interhemispheric fissure []. Cerebral angiography performing was associated with a high risk of rebleeding and patient’s condition worsening.\nBecause of a critical condition of the patient, we decided to treat the patient conservatively. The main protocol includes treatment of cerebral vasospasm and intracranial hypertension. This choice was explained by the possible need for trapping the A1-segment with revascularization, which could lead to worsen of the patient’s condition and an unfavorable outcome.\nAfter 12 days, when the patient condition was stabilized we performed a right-sided lateral supraorbital craniotomy, microsurgical clipping of the eccentrically FA on the A1 segment of ACA.\nTraditional microneurosurgical technique was used. The aneurysmal dilatation occupied the distal part of the A1 segment. Along with fibrin masses in the area of the rupture the eccentrically fusiformed part of the aneurysm was visualized which was adhered to the optic nerve. In this case, the posterior wall of the artery was not changed. Aneurysm was dissected and clipped. There were no intraoperative complications.\nThe patient was extubated in the operating room and transferred to the intensive care unit. The postoperative period was uneventful. On the CT scan there are no postoperative complications.\nIntraoperative photo and the CT scans of the brain in [].\nThe patient was discharged without neurological deficit on the day 9th day after surgery.