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.
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.