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MRI, CT angiography and dynamic angiography. (A) Acute cerebellar infarction on initial MRI. (B) Bilateral vertebral artery aneurysms (arrows) on CT angiography. (C) Both aneurysms (arrows) are located at the atlantoaxial joint level. (D) Higher magnification of panel C, viewed from the right posterior side. Asterisks show facets of the atlantoaxial joints. (E-G) Angiography reveals a mild enlargement of the left aneurysm on neck extension (F) and an irregular endothelial surface near the aneurysm on neck rotation to the left (G, arrowhead), compared with the neutral position (E). Arrows indicate left vertebral artery aneurysm. (B-D: posterior views; E-G: anterior views.)
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Brain MRI revealed acute infarction involving the bilateral cerebellar hemispheres (Fig. 1A) and occipital lobes. After re-evaluating the cervical CT angiography from the first admission, we noticed tiny VA aneurysms bilaterally at the level of the AAJ (Fig. 1B-D), and therefore performed dynamic angiography. The left VA aneurysm showed a mild enlargement on neck extension, and an irregularity of the endothelial surface of the VA near this aneurysm was observed on neck rotation to the left (Fig. 1E-G).
Clinical course. Monotherapy with aspirin or warfarin did not stop stroke recurrence. Recurrences stopped after temporary immobilization of the atlantoaxial joint using a soft cervical collar, together with the administration of an anticoagulant and cilostazol.
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The patient was discharged on warfarin instead of aspirin (Fig. 2), and the dose was adjusted to achieve a prothrombin time international normalized ratio (PT-INR) of 2.38.
CT angiography before and after treatment. The left panels show axial images of CT angiography performed on first admission. The right panels show axial images of CT angiography performed 1 year after treatment with neck collar fixation and antithrombotics. The slice thickness is 1 mm. Both aneurysms have decreased in size, with the left aneurysm becoming undetectable. Arrows indicate vertebral artery (VA) aneurysms. Arrowhead in the right upper panel indicates the position of the left VA aneurysm on the first CT angiography.
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MRI during 2 years of observation. Moreover, follow-up CT angiography has demonstrated the shrinkage of both aneurysms, with the left lesion becoming undetectable by 1 year after starting combination therapy with the cervical collar and antithrombotics (Fig. 3).