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 56-year-old male patient came to the emergency room due to a right-sided occipital headache and vertigo, which suddenly began three days before the visit, and a symptom of tilting to the right, which began one day before the visit. There was no history of an external injury within the past one week. The patient did not have any underlying diseases, history of migraines, or risk factors for stroke, except for smoking. He also did not have a history of taking antiplatelet agents. When the patient visited the emergency room, his blood pressure was 160/100 mmHg, the pulse rate was 62/min, breathing rate was 19/min, and body temperature was 36.5 °C. The results of a neurological examination showed lateropulsion to the right side, hypoesthesia on the right side of the face, ataxia in the right upper and lower limbs, and the NIH stroke scale was 2. The results of serological studies and electrocardiography were normal.\nThe diagnosis was determined to be an acute ischemic stroke because the diffusion weighted imaging (DWI) of MRI revealed a high signal intensity area in the right lateral medulla. CT angiography (CTA) was taken first at 3 days after the symptom occurred. HR vw-MRI was taken a day after (at the 4th-day). The right PICA was not observed in the first CTA, and partial spontaneous recanalization was observed on the time-of-flight MR angiography (TOF-MRA), which was taken one day after. Moreover, the sagittal 3D T1 weighted HR vw-MRI showed a T1 hyperintense intramural hematoma in the right proximal PICA (Fig. ). However, a T2 weighted 3D curved MPR image revealed the luminal dilation and intimal flap in the right proximal PICA (Fig. ). The patient was diagnosed with spontaneous isolated PICA dissection on the basis of the neurological symptoms and imaging. He was treated with antiplatelet agents and the neurological symptoms of the patient improved during course of admission.