A 39 year-old male without past notable medical history was admitted with a sudden headache and neck stiffness. Brain computed tomography (CT) demonstrated evidence of Fisher Grade III subarachnoid hemorrhage (SAH) predominance of the pre-pontine, left ambient and quadrigeminal cistern (), and a fusiform aneurysm of a left distal SCA was revealed on the CT angiography (). Subsequent digital subtraction angiography (DSA) revealed the fusiform dilatation (12 mm length; 4.5 mm width) involving the ambient segment of the left distal SCA. The left SCA was duplicated ahead of the aneurysm and there was sufficient collateral circulation from the ipsilateral anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) (). The aneurysm was treated by endovascular occlusion of the aneurysm sac and the involved branch. Under general anesthesia an Excelsior SL-10 microcatheter was used to access the aneurysm. Seven detachable platinum coils were used to obliterate the lesion. Post-procedural angiography showed complete occlusion of the aneurysm sac and involved the SCA branch (). There was no immediate complication after embolization. Diffusion MRI was done 8 hours after embolization. MRI revealed scattered high signal change on the left posterior tegmentum, superior vermis, and superior part of the left cerebellum (). Left sixth nerve palsy occurred in the patient 1 day after EVT. The symptom completely recovered within 1 week of the post-procedural period. No neurological deficit was seen during the clinical 3-month follow-up.
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.