A 28-year-old male without any previous medical history experienced right hemiplegia after a paroxysmal headache during sexual intercourse. He had a drowsy mentality and dysarthria. The National Institutes of Health Stroke Scale (NIHSS) score was 12. The brain magnetic resonance image (MRI) showed a pontine infarction (). The anterior-posterior view of his vertebral angiogram demonstrated an abrupt filling defect at the mid-basilar artery where the proximal margin of the defect was somewhat blurred and the distal was clearly circumscribed. On the lateral view, the abrupt filling defect was located at the anterior wall of the artery and the distal flow was compromised by a luminal stenosis (). These angiographic findings were highly suggestive of an anterior wall dissection of the basilar artery where the false lumen was filled up with mural hematoma.\nSince his neurological status had been deteriorating, a subsequent endovascular procedure was performed. After confirmation of the anatomical relationship between the true and false lumens, a microwire was navigated into the distal portion across the true lumen with extremely delicate handling to avoid incorrect cannulation into the false lumen. At the first trial of microwire navigation, it went into the intramural hematoma, and a clear resistance was noticed. Then, it was slightly pulled back and advanced again following the posterior wall of the diseased segment for a successful navigation. This maneuver confirmed presence of BAD. Then, a stent was deployed fully covering the lesion including some safety margins. After the stenting procedure, the distal flow was completely restored without residual false lumen (). A week later, he was able to walk unassisted. He discharged without any neurological deficits.
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.