case_images: PMC5259648_01
case_images: (a) (Top) sagittal T1-weighted contrast enhanced brain magnetic resonance imaging (MRI) scan showing a subacute ischemic lesion of the inferior left cerebellar hemisphere in the left posterior-inferior cerebellar artery (PICA) territory and chronic cerebellar and occipital ischemic lesions; (bottom) axial T1-weighted contrast enhanced MRI image of the neck showing a giant fusiform aneurysm (arrow), containing an eccentric thrombotic formation, originating from the left vertebral artery. (b) Left subclavian angiograms showing (left) the displasic and tortuous aspect of the giant aneurysm and (right) aneurysm exclusion after the endovascular treatment by deposition of GDC vortex spirals in the proximal segment of left vertebral artery (VA) (arrow). (c) Late sequences of right vertebral angiogram performed six years after the endovascular procedure showing full revascularization of the rostral part of the aneurysm by retrograde blood flow from the patent vertebrobasilar axis. (d) Diffusion-weighted imaging (DWI) brain MRI showing new acute ischemic lesions of the cerebellum and the brainstem (arrows). (e) Sonography and Color Doppler Ultrasound of neck vessels showing the aneurysm (3.5 cm) and the biphasic flow in the left vertebral artery supportive of the embolic etiology of the new ischemic stroke. (f) Surgery of the giant aneurism by aneurysmorraphy with thrombectomy: aneurysm exposure and isolation from the surrounding tissue.
case_images: CRINM2017-2571630.001.jpg
case_images: PMC5259648_01_CRINM2017-2571630.001.jpg
case_images: fig1
case_images: Imaging (MRI) showed subacute ischemic lesion in the left cerebellar hemisphere and bilateral cerebellar and occipital chronic ischemic lesions (Figure 1(a)). Major cardioembolic sources, alterations of the coagulation cascade, and mitochondrial diseases were excluded. Intracranial MRI angiography was normal, while neck-MRI and angiography of cervical vessels disclosed a primary fusiform 4 cm wide aneurysm originating from the V1 portion of the left VA and containing an eccentric intraluminal thrombotic formation (Figure 1(a)), highly suggestive of being responsible of the multiple ischemic strokes. Therefore, an endovascular procedure was performed with deposition of three Guglielmi Detachable Coils (GDC) 18-vortX  (2 mm x 4 cm, 2 mm x 5 cm, and 2 mm x 3 cm) and three GDC-10 360 (3 mm x 6 cm soft), in the proximal segment of left VA, aimed to interrupt the orthograde blood flow from the aneurysm to the cerebral circulation (Figure 1(b)). Brain MRI revealed acute bilateral cerebellar and brainstem ischemic lesions (Figure 1(d)). Cerebral angiography showed revascularization of the aneurysm by reverse blood flow coming from the contralateral VA (Figure 1(c)). Cervical Color Doppler Ultrasound imaging disclosed a peculiar biphasic blood flow in the left VA directed alternately to the aneurysm and backwards to the basilar artery, which was the pathogenic mechanisms of the new embolic ischemic strokes (Figure 1(e)). Being the aneurysm excluded proximally by the previous endovascular procedure, surgical aneurysmorraphy with thrombectomy was now performed by ligation of distal left VA and complete excision of the aneurysm (Figure 1(f)).