![]() The most common clinical feature of an unruptured VA dissection is a severe occipital headache only or focal ischemia of posterior circulation. 2C) and spontaneous resolution of the left PICA dilatation ( Fig. Findings on follow-up vertebral arteriography three months later showed no recurrence of the right VA dissection lesion ( Fig. This finding suggested that the left PICA lesion was a dissecting aneurysm in a spontaneous healing state. The second angiography performed at four weeks after symptom onset confirmed that the right VA dissection lesion had not recurred and a reduction was observed in the left PICA dilatation ( Fig. The patient's symptoms showed gradual improvement and he recovered without complications. Therefore, we made the decision to provide conservative treatment. In addition, the left PICA lesion was technically less available the diameter of the stenotic segment was too narrow to perform a stent insertion. Finding clues of a dissection in this small vessel was difficult thus, we could not rule out the likelihood of an originally existing fusiform aneurysm. Several possible treatment options were considered for the suggestive dissecting aneurysm on the left proximal PICA. Endovascular treatment of the right VA dissection was performed immediately after cerebral angiography: a Prowler Selector Plus microcatheter (Cordis Neurovascular, Miami, FL) was placed through the dissection segment in the right VA then, two Enterprise stents (Cordis Neurovascular, Miami, FL) were deployed to the right VA dissection site in order to dilate it to cover the dissection ( Fig. 2A), and focal stenosis with a post-stenotic fusiform aneurysmal dilatation of the left proximal PICA, suggesting a dissection with an aneurysm formation ( Fig. Cerebral angiography performed the next day showed a "pearl and string" sign and a double lumen sign in the right distal V4 segment of the VA involving the origin of the right PICA, indicating a spontaneous dissecting aneurysm ( Fig. On the lumbar tapping, there was no evidence of SAH. The MRA showed tapered narrowing of the right VA at the junction of the right VA and PICA, and fusiform dilatation of the anterior medullary segment of the left PICA ( Fig. However, a high signal intensity representing an intramural hematoma was distinguished from a flow-related enhancement of the VA on the source image of time-of-flight (TOF) - magnetic resonance angiography (MRA) ( Fig. In addition, no abnormality was observed on magnetic resonance imaging (MRI). Findings on a computed tomographic (CT) scan performed on admission showed no evidence of intracranial hemorrhage. He had no history of trauma or remarkable medical or familial history. Although he had dizziness and nausea, findings on his neurological examination were normal. A 42-year-old previously healthy male patient complained of sudden onset of a severe right-sided occipital headache for one day.
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