case_images: PMC10481815_01
case_images: Imaging findings on admission. Cervical spine computed tomography (CT) showing no cervical dislocation or spinal canal stenosis (a), but there were fractures in the left lateral mass and transverse process of Atlas, with no high density area suggestive of a thrombus in the foramen transversum. The white arrow indicates the fractures in the left lateral mass and transverse process of Atlas (b and c). CT angiography showing the left vertebral artery occluded at the level of the foramen transversum of Atlas. Both vertebral arteries are similar in diameter, and the left vertebral artery V4 segment and left posterior inferior cerebellar artery are depicted through the right vertebral artery. White arrow indicates occlusion (d). Magnetic resonance angiography showing no blood flow signal in the left vertebral artery (e). Diffusion-weighted magnetic resonance imaging showing no acute cerebral infarction (f).
case_images: SNI-14-278-g001.jpg
case_images: PMC10481815_01_SNI-14-278-g001.jpg
case_images: F1
case_images: Cervical spine computed tomography (CT) showed no cervical dislocation or spinal canal stenosis [Figure 1a]; there were fractures in the left lateral mass and transverse process of Atlas, with no high density area suggestive of a thrombus in the foramen transversum [Figures 1b and c]. CT angiography showed occlusion of the left vertebral artery at the level of the foramen transversum of Atlas, both vertebral arteries were similar in diameter, and the left intracranial vertebral artery and left posterior inferior cerebellar artery were depicted through the right vertebral artery [Figure 1d]. Magnetic resonance angiography of the head showed no blood flow signal in the left vertebral artery [Figure 1e], but diffusion-weighted magnetic resonance imaging showed no acute cerebral infarction [Figure 1f].
case_images: Imaging findings at first and second hospitalizations. Magnetic resonance angiography on day 2 showing spontaneous recanalization of the left vertebral artery (a). Magnetic resonance angiography on day 6 showing further increased blood flow signal in the left vertebral artery and vessel wall irregularity of the left vertebral artery at the level of the left foramen transversum of Atlas. White arrow indicates vessel wall irregularity (b). Magnetic resonance angiography on day 20 showing occlusion of the left vertebral artery (c). Diffusion-weighted magnetic resonance imaging on day 20 showing acute cerebral infarction in the left posterior inferior cerebellar artery territory (d). Computed tomography (CT) of the head on day 20 showing a high density area in the left vertebral artery V4 segment (e). CT angiography on day 20 showing severe stenosis of the left vertebral artery at the level of the foramen transversum of Atlas, with no visualization of the left posterior inferior cerebellar artery. White arrow indicates severe stenosis of the left vertebral artery (f).
case_images: SNI-14-278-g002.jpg
case_images: PMC10481815_01_SNI-14-278-g002.jpg
case_images: F2
case_images: Magnetic resonance angiography on day 2 showed spontaneous recanalization of the left vertebral artery, but diffusion-weighted magnetic resonance imaging showed no acute cerebral infarction [Figure 2a]. Magnetic resonance angiography on day 6 showed further increased blood flow signal in the left vertebral artery and vessel wall irregularity of the left vertebral artery at the level of the left foramen transversum of Atlas [Figure 2b]. CT a high density area in the left vertebral artery V4 segment [Figure 2e]. CT angiography showed severe stenosis of the left vertebral artery at the level of the foramen transversum of Atlas, with no visualization of the left vertebral artery V4 segment and left posterior inferior cerebellar artery [Figure 2f]. Although the patient continued to take aspirin, we judged that the cerebral infarction was caused by thrombus formation associated with dissection of the left vertebral artery.
case_images: Intraoperative imaging findings. Left subclavian arteriography showing antegrade blood flow in the left vertebral artery above the level of the foramen transversum of Atlas. Black arrow indicates severe stenosis of the left vertebral artery (a). Microcatheter angiography showing severe stenosis of the left vertebral artery at the level of the foramen transversum of Atlas, a muscular branch proximal to the stenosis, and a branch of the posterior meningeal artery distal to the stenosis. Black arrow indicates severe stenosis of the left vertebral artery (b: frontal view/c: lateral view). Right vertebral artery angiography with the left vertebral artery blocked showing a thrombus in the left vertebral artery V4 segment and occlusion of the left posterior inferior cerebellar artery. Black arrowheads indicate a thrombus in the left vertebral artery V4 segment (d). Images after coil embolization. The black arrow indicates the severe stenosis of the left vertebral artery (e: frontal view/f: lateral view). Left vertebral artery angiography showing good embolization (g). Right vertebral artery angiography showing good visualization of the main intracranial artery (h).
case_images: SNI-14-278-g003.jpg
case_images: PMC10481815_01_SNI-14-278-g003.jpg
case_images: F3
case_images: Atlas [Figure 3a]. Atlas, a muscular branch proximal to the stenosis, and a branch of the posterior meningeal artery distal to the stenosis [Figures 3b and c]. Antegrade blood flow in the left vertebral artery V4 segment could not be confirmed. Right vertebral artery angiography, in which the left vertebral artery V2 segment was blocked with the Pinnacle blue 27, showed a thrombus in the left vertebral artery V4 segment and occlusion of the left posterior inferior cerebellar artery [Figure 3d]. Parent artery occlusion was performed using 15 detachable coils from the distal to proximal side of the stenosis, including the origin of the vertebral artery muscular branch and the posterior meningeal artery [Figures 3e and f]. The left vertebral artery angiography confirmed the absence of antegrade blood flow in the left vertebral artery [Figure 3g]. The procedure was completed after confirming that the right vertebral artery angiography showed good visualization of the main intracranial artery [Figure 3h].
case_images: Postoperative imaging findings. Magnetic resonance angiography showing occlusion of the left vertebral artery (a). Diffusion-weighted magnetic resonance imaging showing no new cerebral infarction (b). Computed tomography angiography showing occlusion of the left vertebral artery (c).
case_images: SNI-14-278-g004.jpg
case_images: PMC10481815_01_SNI-14-278-g004.jpg
case_images: F4
case_images: Magnetic resonance angiography on day 21 showed occlusion of the left vertebral artery [Figure 4a] and diffusion-weighted magnetic resonance imaging no new cerebral infarction [Figure 4b]. CT angiography showed occlusion of the left vertebral artery [Figure 4c].