PMC9267306_01
(a) Patent bilateral vertebral arteries (arrow) on CTA neck from three years prior to presentation; (b) admission head MRI (143 min after symptom onset) which showed small punctate infarction in the left medulla oblongata (arrow).
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Admission CTA (225 min after symptom onset) showed significant stenosis in the basilar artery, and occlusion of the left V4 segment of the vertebral artery(arrow). Both bilateral posterior cerebral arteries were patent at this time (arrow).
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Head and neck CT angiography (CTA) was performed, which showed significant stenosis in the basilar artery, and occlusion in the V4 segment of the left vertebral artery (Figure 2).
DSA (8 h after symptom onset) showed (a) significant stenosis in the right V4 segment of the vertebral artery and occlusion in the left PCA (arrow); (b) occlusion in the left V4 segment of the vertebral artery (arrow).
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Digital subtraction angiography (DSA) showed significant stenosis in the V4 segment of the right vertebral artery, occlusion in the V4 segment of the left vertebral, and left posterior cerebral arteries (Figure 3).
Head CT (18 h after symptom onset) showed ischemic infarcts in the left parieto-occipital lobe and thalamus (arrow).
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CT brain the next day showed acute infarcts in the left parieto-occipital region and the left thalamus (Figure 4).
Repeat head and neck MRA (25 days after symptom onset) showed persistent stenosis in the bilateral V4 segments of the vertebral arteries and patency in bilateral posterior cerebral arteries (arrow).
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Repeat magnetic resonance angiography (MRA) head and neck was performed 25 days after presentation, which showed persistent stenosis in the V4 segments of the bilateral vertebral arteries, but patent bilateral posterior cerebral arteries (Figure 5).