Isolated cerebellar stroke in a paediatric patient with typical haemolytic uraemic syndrome: a case report and literature review.

Haemolytic Uraemic Syndrome (HUS) is a rare medical condition characterised by microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. Neurological complications are documented but rarely involve the cerebellum. We present a unique case of a 23-month-old male with HUS triggered by Escherichia coli-O157 (E.coli-O157) infection leading to an isolated cerebellar stroke.The patient initially presented with fever, bloody stools, and seizures. Confirmation of E.coli-O157 infection was obtained, and MRI revealed an isolated cerebellar stroke. Treatment included supportive care, anticoagulation for a right atrial thrombus, with gradual improvement observed.This case highlights the unusual occurrence of isolated cerebellar stroke in HUS patients, emphasising the importance of promptly recognizing manifestations of the central nervous system and the necessity for a multidisciplinary approach. Finally, a comprehensive literature review was conducted to identify cases of HUS patients with cerebellar involvement.

Prevalence of anatomical variations at the suboccipital (V3) segment of the vertebral artery: a systematic review.

BACKGROUND AND OBJECTIVE: A recent meta-analysis on the incidence of iatrogenic injury to the VA has revealed that patients with variant anatomy are more prone to iatrogenic injury. Therefore, this review is designed to investigate the incidence of variations in the suboccipital component of the vertebral artery in different population groups according to the available literature. METHODS: This systematic review was conducted according to PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The review is based on a comprehensive and extensive search of PubMed, Google Scholar, and ResearchGate. The following search terms were used: "vertebral artery" AND "suboccipital segment" AND "anomalies/anatomical variations of the V3 segment." Reference lists of all extracted articles were also extensively searched for references to any further relevant publications. RESULTS: A total of 17 papers met the inclusion criteria. The 17 studies corresponded to a total of 10,820 patients. A persistent first intersegmental artery was registered in 1.8% (197 out of 10,820) of the patients. Extradural PICA origin was observed in 1.6% (175 out of 10,820) of the patients. Fenestration was detected in 0.7% (72 out of 10,820) of the patients. CONCLUSION: The authors summarize the incidence of vascular variation at the suboccipital segment of the VA in different population groups across the Asian, European, American, and African continents. Awareness of the extent of possible anatomical variation will help interpret radiographs, which will enhance the identification of vascular pathologies and reduce the risk of iatrogenic injury.

Occipital artery-to-PICA bypass: how I do it.

BACKGROUND: Posterior inferior cerebellar artery (PICA) aneurysms are uncommon, and their management is challenging because of the complex angioarchitecture of the PICA and the frequently nonsaccular aneurysm presentation. Endovascular therapy may not be feasible. METHODS: We describe our technique of clip trapping with occipital artery (OA)-to-PICA bypass to treat a PICA aneurysm. Because the aneurysm affected the ipsilateral, dominant PICA, an OA-PICA bypass was chosen to ensure adequate flow and reduce risk to the contralateral PICA supply. CONCLUSION: The OA-PICA anastomosis is a safe and effective method to successfully achieve flow preservation with bypass reconstruction and aneurysm trapping.

Usefulness of combining CISS and digital subtraction angiography in diagnosis of isolated posterior inferior cerebellar artery dissection.

A 63-year-old man was admitted to our stroke center with brain infarction in the left posterior inferior cerebellar artery (PICA) territory. The initial MRI showed no findings suggestive of arterial dissection, and post-discharge MRI showed no temporal changes. Digital subtraction angiography (DSA) revealed vasodilation of the proximal portion of the PICA but it was uncertain whether dissection was present. Discrepancy between the outer contour seen on constructive interference in steady state (CISS) MRI and the inner contour seen on DSA suggested the presence of intramural hematoma. The patient was diagnosed with brain infarction caused by isolated PICA dissection (iPICAD). Imaging evaluation of combined CISS and DSA may be particularly useful for identification of small iPICAD lesions.

A posterior inferior cerebellar artery of C2 transverse foramen level origin that entered the spinal canal via the C1/2 intervertebral space demonstrated by computed tomography angiography.

PURPOSE: To describe a case of a posterior inferior cerebellar artery (PICA) of C2 transverse foramen level vertebral artery (VA) origin that entered the spinal canal via the C1/2 intervertebral space. CASE REPORT: A 48-year-old man with posterior neck pain underwent computed tomography (CT) angiography and selective left vertebral angiography. Arterial dissection was found at the distal V2 segment of the left VA on subtracted CT angiography. The left PICA arising from the VA at the level of C2 transverse foramen was identified on CT angiography with bone imaging. This PICA of extracranial origin entered the spinal canal via the C1/2 intervertebral space, just like a PICA of C1/2 level origin. DISCUSSION: The origins of PICAs show several variations. PICAs originating at the extracranial C1/2 level VA are relatively rare, with a reported prevalence of approximately 1%. Our patient had a left PICA arising from the VA at the level of the C2 transverse foramen. No similar cases have been reported in the relevant English-language literature. We speculated that the proximal short segment of the PICA arising from the C1/2 level VA regressed incidentally and that the distal segment of the PICA was supplied by the muscular branch of the VA arising from the level of the C2 transverse foramen. CONCLUSION: We reported the first case of PICA arising from the C2 transverse foramen level VA. CT angiography with bone imaging is useful for identifying a PICA arising from the extracranial VA.

Occipital artery-posterior inferior cerebellar artery bypass: a cadaveric feasibility study.

PURPOSE: To demonstrate that occipital artery (OA)-p1 posterior inferior cerebellar artery (PICA) bypass can be an alternative for complex posterior circulation aneurysms. METHODS: A far-lateral approach to craniotomy was performed on 20 cadaveric specimens, and the OA was obtained 'in-line.' Its length, diameter, and the number of p1/p2 and p3 segmental perforators were determined, and the relationship between the caudal loop and cerebellar tonsil position was also assessed. The distance between the PICA's origin and the cranial nerve XI (CN XI), the buffer length above the CN XI after dissection, the OA length required to complete the OA-p1/p3 PICA bypass, and the p1 and p3 segment diameters were all measured. A bypass training practical scale (TSIO) was used to evaluate the quality of the anastomosis. RESULTS: All specimens underwent OA-p1 PICA end-to-end bypass and had favorable results for the TSIO score, 15 sides underwent OA-p3 PICA end-to-side bypass, and the other bypass protocols were less common. The buffer length above the CN XI after dissection, the distance between the PICA's origin and the CN XI, and the first perforator were all of sufficient length. The direct length of the OA needed to complete the OA-p1 PICA end-to-end bypass was significantly less than the available length and the OA-p3 PICA end-to-side bypass, with the OA matching the p1 segment diameter. The number of p1 perforators was less than that of p3, and the OA diameter was equal to that of the p1 segment. CONCLUSION: OA-p1 PICA end-to-end bypass is a feasible alternative in cases in which p3 segment has high caudal loops or anatomic anomalies.

Posterior inferior cerebellar artery originating from the posterior meningeal artery mimicking dural arteriovenous fistula.

PURPOSE: Many variations in the origin of the posterior inferior cerebellar artery (PICA) have been reported. To our knowledge, only one case of a PICA originating from the posterior meningeal artery (PMA) has been reported. METHODS: We describe a case with a PICA that was supplied retrograde from the distal segment of the PMA, mimicking a dural arteriovenous fistula on magnetic resonance angiography (MRA). RESULTS: A 31-year-old man was admitted to our hospital with a sudden occipital headache and nausea. MRA showed a hyperplastic left PMA, continuing to an abnormal vessel that was suspicious for venous drainage. Digital subtraction angiography revealed the left PMA originated from the extradural segment of the vertebral artery and then connected to the left PICA near the torcula. The cortical segment of the PICA flowed retrograde, which appeared as venous reflux on MRA. A second PICA originated from the extradural segment of the left vertebral artery and perfused the tonsillomedullary and televelotonsillar segment of the left PICA territory. CONCLUSION: We present an anatomical variant of the PICA mimicking a dural arteriovenous fistula. Digital subtraction angiography is useful for diagnosis of the cortical segment of the PICA flowing retrograde from the distal segment of the PMA because signal intensity in MRA of retrograde flow tends to decrease and diagnosis may be difficult. During endovascular treatment and open surgery, we should note that ischemic complications may occur due to the potential anastomosing channels between cerebral and dural arteries.

Hiccups before a Pulmonary Embolism Speak against This as a Cause.

How to cite this article: Finsterer J. Hiccups before a Pulmonary Embolism Speak against This as a Cause. Indian J Crit Care Med 2023;27(3):228.

Sinus arrest following acute lateral medullary infarction.

Lateral medullary syndrome (LMS) is an ischemic stroke of the medulla oblongata that involves the territory of the posterior inferior cerebellar artery. LMS is often missed as the cause of autonomic dysregulation in patients with recent brain stem stroke. Due to the location of the nucleus tractus solitarius (NTS), the dorsal vagal nucleus, and the nucleus ambiguous in the lateral medulla oblongata, patients with LMS occasionally have autonomic dysregulation-associated clinical manifestations. We report a case of LMS-associated autonomic dysregulation. The case presented by recurrent syncope, requiring permanent pacemaker placement. This case shows the importance of recognizing LMS as a potential cause of life-threatening arrhythmias, heart block, and symptomatic bradycardia. Extended cardiac monitoring should be considered for patients with medullary strokes.

Isolated ruptured dissecting aneurysm of PICA with extremely narrow neck managed by a novel endovascular technique-a case report and review of literature.

Dissecting aneurysms of posterior inferior cerebellar artery (PICA) are usually extensions of vertebral artery dissection. Isolated dissecting aneurysms of PICA are extremely rare. A 5-month-old female child presented with history of fall from a height of around 2 ft., followed by incessant crying and multiple episodes of vomiting. The anterior fontanelle was lax. Plain CT scan brain showed IVH in the fourth ventricle with no hydrocephalus. Twenty-four hours after admission, the child had one episode of vomiting and became unresponsive. The child was intubated, and a repeat CT scan brain showed thick acute SDH in the posterior fossa with hydrocephalus. Emergency suboccipital craniectomy and evacuation of thick acute subdural hematoma were done. Organized clot noted in the midline between the tonsils was not removed. Digital subtraction angiography (DSA) done 48 h after surgery showed ruptured dissecting aneurysm of left PICA. Endovascular temporary parent artery occlusion by coil deployment was performed, after which a check angiogram revealed complete exclusion of aneurysm from circulation. Endovascular proximal parent artery occlusion is the preferred treatment modality for dissecting aneurysms of PICA. Selective coil or Onyx embolization of the aneurysm with parent vessel preservation technique is a valid and increasingly used alternative. In this case, a novel technique of endovascular temporary parent artery occlusion by coil deployment was performed successfully. This technique may be recommended in select cases.

Symptomatic ischemic complications following endovascular treatment of vertebral artery dissecting aneurysms.

PURPOSE: The aim of this study is to investigate the clinical and radiological features related to the symptomatic ischemic complications of vertebral artery dissecting aneurysm (VADA) following endovascular treatment (EVT). METHODS: The clinical and radiological features of 127 VADAs, which were treated in a single tertiary institute between September 2008 and December 2020, were retrospectively reviewed. We defined a thrombosed aneurysm as being one which the thrombus was in the aneurysm in magnetic resonance imaging (MRI). Symptomatic ischemic complication was defined as a case in which acute infarction was confirmed on diffusion weighted image after EVT with associated clinical symptoms. Univariate and multivariate analyses were executed to demonstrate the associations between symptomatic ischemic complication and characteristics of VADA. RESULTS: The rate of symptomatic ischemic complication was 13.4% (17 of 127). The thrombosed aneurysms were observed in 24.4% (31 of 127) and posterior inferior cerebellar artery (PICA) involvement was shown in 38.6% (49 of 127). Multivariate logistic regression analysis demonstrated that thrombosed aneurysms (odds ratio [OR] = 8.54, 95% confidence interval [CI] 1.98-36.87, p = 0.004) and PICA involvement (OR = 4.26, 95% CI 1.03-17.68, p = 0.046) were significantly associated with symptomatic ischemic complications following EVT. CONCLUSION: This study showed that the VADAs with intra-aneurysmal thrombose and PICA involvement may be independent risk factors for symptomatic ischemic complications following EVT. Therefore, when the thrombosed VADAs with PICA involvement are observed, practitioners may consider close postoperative monitoring for early detection of ischemic complications.

Common trunk anomaly of the anterior and posterior inferior cerebellar artery in hemifacial spasm.

BACKGROUND: The common trunk anomaly of the anterior and posterior inferior cerebellar artery (APC) is a variant artery that causes a hemifacial spasm (HFS). The anatomical characteristics include a large diameter of the trunk and the existence of the bifurcation near the facial nerve root entry zone (REZ). Despite APC being encountered at a constant rate in microvascular decompression (MVD), the anatomical and technical issues of transposing APC have not been entirely focused on yet. METHODS: We reviewed our 68 cases with APC involvement. Patient background, radiological findings, and operative video recordings were reviewed retrospectively. The location of the bifurcation of APC and the distribution of perforators were investigated. Surgical outcomes were assessed in the long term. RESULTS: APC involvement was diagnosed preoperatively in all cases by careful observation with MRI. Three-dimensional images determined the anatomical characteristics of APC and depicted the relationship with the facial nerve. All patients had a bifurcation close to the root entry zone that was required to transpose, including the common trunk and the distal branches, to achieve sufficient decompression. While adequate transposition from the REZ was accomplished in most cases, it was difficult to complete transposition due to short perforators in 6 patients (8.8%), resulting in interposition. Fifty-three patients (77.9%) became spasm free immediately after surgery, 66 patients (97.1%) were after 6 months, and all patients (100%) became spasm free within a year. Spasm-free status was maintained during the follow-up period (4.7 years) in all patients except one in whom facial spasm recurred 2 years after the initial surgery. CONCLUSIONS: Transposing the common trunk with the bifurcation and distal branches contributes to obtaining favorable surgical outcomes in APC-related HFS.

Ocular Lateral Deviation as a Vestibular Clinical Sign of Medial Posterior Inferior Cerebellar Artery Strokes: A Case Report.

We report a case of posterior circulation stroke that presented with a unique ocular vestibular sign called Ocular Lateral Deviation (OLD). OLD is eye deviation to one side that is made more prominent by brief eye closure. OLD has been reported to occur ipsilesional in a third of medullary strokes, and occasionally in other posterior fossa strokes. Here we report a case of acute stroke that presented with contralesional eye deviation consistent with OLD due to inferior vermis stroke. To our knowledge, this presentation has not been reported before. Clinicians should be aware of potential ocular manifestations of posterior circulation strokes, as these syndromes may not generate significant NIHSS scores and may be missed.

Duplicated posterior inferior cerebellar arteries one of which was supplied by the jugular branch of the ascending pharyngeal artery.

PURPOSE: To describe a case of duplicated posterior inferior cerebellar arteries (PICAs), one of which was supplied by the jugular branch of the ascending pharyngeal artery (APA). CASE REPORT: A 62-year-old man with cerebral infarction underwent cranial magnetic resonance (MR) imaging and MR angiography. MR angiography showed a hyperplastic left APA, that was found to enter the posterior cranial fossa and continue to the PICA. Another left PICA arising from the V4 segment of the left vertebral artery (VA) and a tiny left anterior inferior cerebellar artery (AICA) were also identified. The source images of MR angiography revealed that the anomalous artery was passing through the medial side of the jugular foramen pars vascularis. The two left PICAs did not fuse to each other. DISCUSSION: There are four types of the PICA arising from the carotid system: (1) the PICA arises from the cavernous segment of the internal carotid artery (ICA) (persistent trigeminal artery variant); (2) the PICA arises from the cervical segment of the ICA (persistent hypoglossal artery variant); (3) the PICA arises from the APA via the hypoglossal canal; and (4) the PICA arises from the APA via the jugular foramen. Two PICAs sometimes arise from the V4 segment of the VA. In this common variation, the AICA is usually absent. This is the first reported case involving the association of (4) and a duplicated PICA with a tiny AICA. CONCLUSION: To identify this variation, careful observation of source images and creation of partial maximum-intensity-projection images of MR angiography are important.

Microneurosurgical Management of Posterior Inferior Cerebellar Artery Aneurysms: Results of a Consecutive Series.

Aneurysms of the posterior inferior cerebellar artery (PICA) are uncommon. The complex anatomy of PICA and its intimate relationships with medulla, lower cranial nerves, and jugular tubercle makes the surgical treatment of these aneurysms fascinating. The reported is study aimed at a critical review of the overall results of a personal series of PICA aneurysms, treated by the senior author, R. Galzio. Demographics, charts, videos, outcome, and follow-up of a cohort of PICA aneurysms managed in the last 10 years were retrospectively analyzed, focusing only upon those treated with microneurosurgery. Twenty-five patients, harboring a single aneurysm, were operated on. Fifteen aneurysms were ruptured. Nineteen were proximal, all of these being been treated through a far-lateral approach. Trans-condylar or trans-tubercular variants were rarely necessary and however reserved to peculiar cases. Twenty-three aneurysms underwent direct treatment consisting of clip ligation. At 6-month follow-up, 60% of patients had a modified Rankin Score (mRS) of 0-2. Given the high anatomical variability of both PICA and patients' bony anatomy, a case-by-case meticulous preoperative imaging evaluation is mandatory for the choice of the most suitable and tailored surgical corridor which, in turn, is pivotal to achieve the best outcome.

Posterior Circulation Aneurysms: A Critical Appraisal of a Surgical Series in Endovascular Era.

The advent of the endovascular era has apparently decreased the role of microneurosurgery for many of the posterior circulation aneurysms. This study consists of a critical appraisal of a retrospective surgical series regarding posterior circulation aneurysms, targeted to define whether microneurosurgery still has a role for some of these. In 28 years, 157 aneurysms were surgically treated, 98 of which ruptured. The Average patient age was 56.7 ± 14.2 years, while in hemorrhagic cases, the mean Hunt-Hess score was 2.17 ± 0.8. Basilar tip, vertebral artery and proximal posterior inferior cerebellar artery were the most frequently involved sites. The treatment consisted of 128 clippings, 19 trappings, 7 wrappings, and 3 bypasses. A total exclusion was achieved in 88.5% of the aneurysms. An average follow-up of 67.1 ± 61.3 months proved no recurrences. The best results were observed in patients <65 years old who harbored small-to-regular aneurysms of the basilar tip, distal cerebellar arteries, or vertebral artery.Clipping proved to be a definitive and durable treatment for a large part of posterior circulation aneurysms, whereas bypass allows for treating aneurysms not amenable for coiling, stenting, or clipping. The present study confirms that microneurosurgery continues to have a paramount role within neurovascular pathology.

Ruptured aneurysm arising at anterior spinal artery as the collateral circulation with bulbar artery supply to posterior inferior cerebellar artery treated by proximal occlusion and occipital artery-posterior inferior cerebellar artery bypass: a case report and literature review.

The cases of aneurysms arising from collateral vessels that supply the posterior inferior cerebellar artery (PICA) are so exceptionally rare that there is no consensus on the optimal treatment. In this report, a patient was presented with subarachnoid hemorrhage caused by a fusiform aneurysm on the right anterior spinal artery, which formed an anastomosis network with bulbar artery and the vessels supplying to the right PICA. We chose to perform proximal occlusion on the anterior spinal and bulbar arteries, using occipital artery-PICA bypass. Our case was the first where proximal occlusion was used concurrently with vascular reconstruction to treat a ruptured aneurysm of collateral vessels supplying to PICA.

How I do it? Posterior inferior cerebellar artery-intracranial vertebral artery reimplantation bypass and trapping of dissecting aneurysm involving the proximal posterior inferior cerebellar artery.

BACKGROUND: Proximal posterior inferior cerebellar artery (PICA) aneurysms are surgically challenging due to the high variability in the anatomy of the PICA origin, their deep-seated nature, and their entanglement with the lower cranial nerves. Direct or reconstructive clipping may not be achievable if the aneurysm is large, or dissecting, or exhibits atherosclerosis or calcification. METHOD: We present a case of a proximal PICA lateral medullary segment (P2) aneurysm that was successfully cured by trapping the aneurysm and reconstructing the PICA using the PICA-intracranial vertebral artery (PICA-V4) via end-to-side reimplantation bypass with the far lateral approach. CONCLUSION: This case demonstrates the feasibility and safety of PICA-V4 reimplantation bypass, especially if the origin of the PICA is highly seated and the intracranial VA, or V4 segment, is long enough and well-exposed supra or under hypoglossal nerves.

Endovascular Treatment of an Arteriovenous Malformation Associated with a Double Origin of the Posterior Inferior Cerebellar Artery.

INTRODUCTION: A double origin of the posterior inferior cerebellar artery (DOPICA) is a rare anatomical variant. Posterior fossa arteriovenous malformations (AVMs), especially cerebellar AVMs, are also not common. Consequently, the association of a DOPICA with a cerebellar AVM is even rare. CASE PRESENTATION: We present a rare case of a pediatric cerebellar AVM supplied by a branch of a DOPICA which was treated endovascularly with NBCA. Total obliteration was achieved in the immediate controls and at 1-year follow-up. CONCLUSION: Navigation through tortuous and long branches from a DOPICA is technically feasible. Although NBCA cure rates are relatively low, when the microcatheter can no longer navigate through the feeding artery, a correct dilution of NBCA with lipiodol can provide adequate penetration of this embolic agent, to obliterate the AVM nidus completely.

Giant aneurysms of the distal posterior inferior cerebellar artery - systematic review.

BACKGROUND: Posterior inferior cerebellar artery (PICA) aneurysms are uncommon and are typically found at the origin or proximal segments of the vessel. Giant aneurysms are uncommon and present unique treatment challenges. Giant distal PICA aneurysms are exceedingly rare and have traditionally been managed via open surgical approaches. METHODS: A total of 207 studies were assessed, identifying 26 cases of giant distal PICA aneurysms from 26 separate publications. One additional case is described followed by a review of presentation, anatomical characteristics, treatment and outcome. RESULTS: Presentation was due to local mass effect in 19 (70%), hydrocephalus in 4 (15%) and acute haemorrhage in 5 (19%). All reported cases were partially (86%) or completely (14%) thrombosed. The telovelotonsillar segment was involved in 18/24 (75%) cases. Two cases (7%) were associated with an arteriovenous malformation. Twenty-two (81%) were managed surgically and 5 (19%) managed endovascularly. Outcome was good in 22 (85%) and poor in one (4%). CONCLUSIONS: Giant distal PICA aneurysms can be managed effectively through a variety of open surgical and endovascular techniques.