PMC4110125_01
Preoperative digital subtraction angiogram (DSA) images in the arterial phase. (A) Anteroposterior (AP) and (B) lateral (Lat) views following contrast injection of the right vertebral artery. The DSA reveals the presence of a bilobed aneurysm arising from the right posterior inferior cerebellar artery with no evidence of cerebral vasospasm. (C and D) Postoperative DSA images in (C) AP and (D) Lat views postcontrast show complete clipping of the posterior inferior cerebellar aneurysm with the clip in situ (dotted oval white line outlining the aneurysm clip), no evidence of residual filling, and the absence of vasospasm. (E and F) Postoperative DSA images one week after the aneurysm clipping revealing angiographic evidence of vasospasm in the posterior circulation on the (E) AP angiogram and (F) the lateral view of the posterior circulation on the angiogram.
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A 54-year-old woman had presented to an outside hospital following rupture of a right PICA with SAH for which she underwent clipping (Fig. 1A-D). Hunt and Hess grade 2 with a Fisher grade 3 reported on her computed tomography (CT) scan. Her postoperative course was complicated by clinical and angiographic cerebral vasospasm with communicating hydrocephalus a week following surgery (Fig. 1E, F).
(A) Preoperative T2-weighted sagittal image of the craniovertebral junction and cervicothoracic spine revealing dilatation of the inferior fourth ventricle with central canal enlargement along with ventral cysts at cervical (C1-2) and cervicothoracic cord (arrow with diamond head). (B) T1-weighted sagittal images postcontrast revealing dilatation of the inferior fourth ventricle (circular arrowhead) with a ventrally placed cyst at C1-2 (diamond head arrow) and enhancement of the adhesions along the ventral aspect of the cervical and upper thoracic cord (open arrowhead).
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A magnetic resonance imaging (MRI) scan of the craniospinal axis revealed dilatation of the fourth ventricle with compression at the CV junction and the adjacent C1 and C2 levels, and a contrast-enhancing cyst wall at the C1-2 and 5-6 levels with a mass effect on the cervical spinal cord (Fig. 2A, B).
(A) Preoperative T2-weighted sagittal image of the thoracic spine revealing dilatation, a cord syrinx with ventral loculated cysts, and adhesions tethering the cord anteriorly and compressing it at the same time (diamond head arrows). (B) T1-weighted sagittal postcontrast images revealing enhancement of the fibrous bands (adhesions) tethering the cord and patchy enhancement of the cyst wall margins (open arrowheads).
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The cervicothoracic scan revealed syringohydromyelia extending upward from the T4-5 level, with ventral cysts and adhesions causing cord compression (Fig. 3A, B).
Postoperative magnetic resonance images at 6 months following surgery. (A) T1-weighted sagittal image of the craniovertebral junction revealing a wide decompression of the posterior fossa and upper cervical canal with diminished fourth ventricular size, absence of upper cord compression by the cyst, and no visible tethering by adhesions (diamond arrowheads). (B) T2-weighted sagittal image of the cervicothoracic spine showing posterior decompression at the cervical and upper thoracic spine (diamond arrowheads) without cord compression, and resolution of the mass effect of the cyst and syrinx.
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She was discharged and her postoperative imaging 6 months following surgery revealed decompression of the posterior fossa and upper cervical and thoracic spine with absence of cystic compression and resolution of the cervicomedullary and thoracic syrinx (Fig. 4A, B).