Bilateral vertebral artery dissection extending to the left posterior cerebral artery: A case report.

Intracranial artery dissection accounts for a small percentage (1%-2%) of all ischemic strokes. Vertebral artery dissection sometimes extends to the basilar artery but very rarely to the posterior cerebral artery. We report a case of bilateral vertebral artery dissection extending to the left posterior cerebral artery with the characteristic distribution of intramural hematoma. A 51-year-old woman presented with right hemiparesis and dysarthria 3 days after sudden neck pain. Magnetic resonance imaging on admission revealed infarcts in the left thalamus and temporo-occipital lobe and findings suggestive of bilateral vertebral artery dissection. No infarct was detected in the brainstem. The patient was treated conservatively. Initially, we suspected that infarction in the left posterior cerebral artery territory had been caused by artery-to-artery embolism from the dissected vertebral arteries. However, T1-weighted imaging on day 15 of admission revealed intramural hematoma extending from the left vertebral artery to the left posterior cerebral artery. Therefore, we diagnosed bilateral vertebral artery dissection extending to the basilar artery and the left posterior cerebral artery. The patient's symptoms subsequently improved with conservative treatment, and she was discharged with a modified Rankin Scale score of 1 on day 62 of admission. In this case, intramural hematoma of the basilar artery was found in the anterior vessel wall. Brainstem infarction is less likely when intramural hematoma is located in the anterior vessel wall of the basilar artery in vertebrobasilar artery dissection. T1-weighted imaging is useful for the diagnosis of this rare condition and can predict potentially impaired branches and possible symptoms.

Acute middle cerebral artery occlusion caused by spontaneous thrombosis of a small internal carotid artery aneurysm: illustrative case.

BACKGROUND: Spontaneous thrombosis of a saccular, unruptured, intracranial aneurysm is rare in nongiant aneurysms. Herein, the authors present a case of acute middle cerebral artery occlusion (MCO) caused by spontaneous thrombus of a small internal carotid artery (ICA) aneurysm. OBSERVATIONS: A 68-year-old woman presented with increased somnolence, right-sided hemiplegia, hemispatial neglect, and total aphagia. Left MCO and a small left ICA aneurysm were suspected based on magnetic resonance angiography (MRA). The authors detected early ischemic lesions from diffusion-weighted imaging (DWI). The DWI-Alberta Stroke Program Early Computed Tomography Score was 6. T2*-weighted imaging (T2*WI) showed a thrombus, the so-called susceptibility vessel sign, at the left MCO site. Another suspected thrombus was also found in the ipsilateral ICA aneurysm. The authors treated acute phase MCO with mechanical thrombectomy (MT), after which secondary stroke prophylaxis consisting of warfarin potassium was started. Since follow-up T2*WI showed the thrombus had disappeared from the left ICA aneurysm and the whole aneurysm was clarified by MRA, coil embolization was performed. After coil embolization, there was no ischemic recurrence. LESSONS: Aneurysms are infrequently found proximal to occlusion sites during MT. If the proximal aneurysm is a potential embolic source, treatment of the said aneurysm may prevent stroke.

The endothelialization on carotid web treated with dual layer stent placement: a case report.

Carotid webs are known to cause acute ischemic stroke in younger adults and have a high recurrence rate. Herein, we report a case of a symptomatic carotid web in a 51-year-old man who was transferred to our hospital after developing consciousness disturbance and left hemiparesis. He was diagnosed with right middle cerebral artery occlusion and underwent mechanical thrombectomy. Because his carotid web was the likely embolic source, we performed carotid artery stenting using a dual-layer stent to crimp the vessel wall and secure closure of the web pocket. Follow-up angiography was performed at 3 weeks after stenting, and endothelialization on the web pocket was confirmed. The high scaffolding effect of the dual layer stent may promote the endothelialization on the carotid web.

Symptomatic interdural cerebrospinal fluid collections after surgery for idiopathic spinal cord herniation: illustrative case.

BACKGROUND: Idiopathic spinal cord herniation (ISCH) is very rare. Some reports have described postoperative ventral cerebrospinal fluid (CSF) collections in patients with ISCH; however, such collections are asymptomatic in most patients, and there is no consensus regarding whether they are part of the natural history or a complication. OBSERVATIONS: A 30-year-old man with ISCH underwent direct closure of a duplicated dura mater. Eight months postoperatively, he developed reworsening of right lower limb paresis and new severe right arm pain and paresis. Three-dimensional magnetic resonance imaging revealed ventral CSF collections, which the authors judged as the responsible lesions. The authors initially considered these collections to be present in the epidural space, extradurally compressing the dural sac and resulting in myelopathy. An epidural blood patch failed; however, a CSF drainage test resulted in dramatic improvement. The authors therefore determined that the CSF collections were located in the interdural space, not the epidural space. A lumboperitoneal (LP) shunt was performed to reduce the CSF pressure. The patient's symptoms improved immediately postoperatively. He had developed no recurrence of symptoms 6 months after surgery. LESSONS: Ventral interdural CSF collections after ISCH surgery can cause reworsening of myelopathy and may be cured by a LP shunt to control CSF pressure.

Target Embolization of Dilated Post-PICA Segment for Ruptured PICA-Involved Type Vertebral Artery Dissecting Aneurysm.

Objective: In parent artery occlusion (PAO) for ruptured vertebral artery dissecting aneurysms (RVADA), target embolization using coils in a short segment to occlude only the vasodilated area containing the rupture point is selected as a first-choice procedure at our institute. We focused on RVADA involving the posterior inferior cerebellar artery (PICA) and evaluated the treatment results. Methods: This study consisted of eight cases with RVADA involving the PICA which were treated between October 2007 and January 2020. Based on radiological findings such as the bleb, the rupture points were located at the affected vertebral artery (VA) distal to PICA in all cases. Target embolization, by which only coiling at the dilated segment distal to the VA was performed. We aimed to preserve blood flow to the PICA. The incidence and extent of medullary infarctions, and neurological outcome were retrospectively assessed. Results: Regarding the diameter of bilateral VA, there were no differences in six cases while the affected VA with RVADA were larger in the remaining two cases. PICA was preserved in all cases but one in which occlusion of complementary PICA was observed. Postoperative medullary infarction was not noted. There was no rebleeding during the follow-up period. However, recanalization of the VA was observed in four cases and additional coil embolization was performed. All patients were discharged with a good outcome (modified Rankin Scale [mRS] 0; seven patients, mRS 2; one patient). Conclusion: Target embolization preserving the PICA in PICA-involved type RVADA was considered to be an effective treatment method for cases whose rupture point was located in the VA distal to PICA orifice.