case_images: PMC4278098_01
case_images: (a) Preoperative axial MRI diffusion-weighted imaging depicting multiple, scattered, and punctate areas of restricted diffusion within the right cerebellar hemisphere. A large territory brainstem or cerebellar stroke was not evident. (b) Anteroposterior (AP) and (c) lateral preoperative DSA displaying severe, near-total occlusive focal plaque at the V4 segment. The ipsilateral PICA does not opacify. (d) 3D-reconstructed images from the postoperative CT-angiogram revealing patency and slight dilation at the endarterectomy site. A single clip at the transected posterior meningeal branch is also seen. (e) Postoperative AP and (f) lateral DSA 10 months postsurgery reveal patency without significant change at the endarterectomy site
case_images: SNI-5-166-g001.jpg
case_images: PMC4278098_01_SNI-5-166-g001.jpg
case_images: F1
case_images: Computed tomography (CT) angiography obtained on admission at our institution showed absent left vertebral flow below posterior inferior cerebellar artery (PICA) and right VA origin stenosis [Figure 1]. Ten-month follow-up angiography revealed satisfactory posterior circulation perfusion, wide patency at the treated VA segment, and mild (non flow-limiting) in-stent restenosis at the right VA origin [Figure 1].
case_images: Intraoperative photographs displaying (a) completion of the endarterectomy using micro-forceps and 6-Penfield microdissector and (b) completion of the nonautologous patch angioplasty. Used with permission from Barrow Neurological Institute
case_images: SNI-5-166-g002.jpg
case_images: PMC4278098_01_SNI-5-166-g002.jpg
case_images: F2
case_images: Endarterectomy was performed without complication in the standard fashion with a Penfield 6 microdissector and microforceps [Figure 2]. Flagstaff, AZ) patch was trimmed and sutured in place with 9-0 prolene, accommodating a slight dilation at the site of the arteriotomy. Frequent and repeated back-bleeding from both the proximal and distal ends of the VA and brisk irrigation with heparinized saline at the anastomosis line was performed at 2-minute intervals during closure to prevent thrombosis [Figure 2].