PMC5234302_01
A diffusion-weighted image showing left brainstem infarction (a). Brain computed tomography images showing right cerebellar hemorrhage, subdural hemorrhage, subarachnoid hemorrhage of the posterior cranial fossa, and intraventricular hemorrhage (b, c)
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F1
A 75-year-old man had a history of left brainstem infarction due to atherosclerotic BA occlusion at the age of 67 years [Figure 1a]. His Glasgow coma scale score was 6, and computed tomography (CT) showed right cerebellar hematoma and subdural, subarachnoid hemorrhage (SAH), and intraventricular hemorrhage at the posterior cranial fossa [Figure 1b and c].
Three-dimensional digital subtraction angiography images showing basilar artery occlusion and a 3.6-mm saccular aneurysm at the cortical segment of the left distal posterior inferior cerebellar artery. (a) anteroposterior view, (b) lateral view
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F2
One week after admission to our hospital, three-dimensional (3D) computed tomography angiography (CTA) and digital subtraction angiography (DSA) revealed a 3.6-mm distal PICA saccular aneurysm at the cortical segment [Figure 2].
Intraoperative images showing the ruptured distal posterior inferior cerebellar artery aneurysm (a) and neck clipping of the aneurysm (b). Indocyanine green videoangiography showing complete neck clipping (c)
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F3
Neck clipping was performed via a midline suboccipital approach in the prone position to prevent re-rupture 2 months after admission [Figure 3].
Intraoperative images showing right superficial temporal artery-superior cerebellar artery (STA-SCA) bypass. (a) preparation of the SCA branch, (b) end-to side anastomosis. Indocyanine green videoangiography demonstrating bypass patency (c)
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F4
Three months after the onset of subarachnoid hemorrhage (SAH), right STA-SCA bypass was performed via the right subtemporal approach in the "parkbench" position to prevent the occurrence of a hemodynamic stress-induced de novo aneurysm and recurrent bleeding [Figure 4].
Postoperative digital subtraction angiography performed a month after bypass surgery. Right external cerebral angiography showing the establishment of new blood vessels from the right superior cerebellar artery to the left superior cerebellar artery (a), and right common carotid angiography showing bilateral posterior cerebral arteries via the posterior communicating artery (b)
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F5
Postoperative DSA confirmed bypass patency supplying the bilateral SCA territory [Figure 5a] and showed bilateral posterior cerebral arteries via the posterior communicating artery [Figure 5b].
Single photon emission computed tomography images at rest showing improvement of cerebellar and occipital blood flow (mL/100 g/min) before (a) and 3 months after (b) bypass surgery
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F6
Single photon emission computed tomography (SPECT) performed 3 months after bypass surgery showed improvement in the cerebellar and occipital blood flow (left cerebellar hemisphere: Before, 23.4 and after, 25.4; right cerebellar hemisphere: Before, 25.2 and after, 29.0; left occipital lobe: Before, 33.2 and after, 38.1; right occipital lobe: Before, 35.4 and after, 37.9 mL/100 g/min) [Figure 6].