PMC9341350_01
A - Brain CT on the first presentation. Intracerebral hemorrhage in the cerebellar vermis and medial aspect of the left cerebellar hemisphere with intraventricular extension; B - Brain CT on first presentation showing supra-tentorial hydrocephalus.
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She was intubated/ventilated and an urgent CT head revealed a large hemorrhage into the cerebellar vermis and left cerebellar hemisphere, extending into the ventricular system and causing supratentorial hydrocephalus. (Figures 1A and 1B).
A - Digital Subtraction Angiogram (DSA) on the first presentation before coiling of the aneurysm. Arrows showing aberrant right PICA and irregular distal branches and a distal aneurysm; B - Digital Subtraction Angiography (DSA) after coiling of the aneurysm.
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The aneurysm was coiled, the hematoma evacuated, and a digital subtraction angiography (DSA) revealed an aberrant branch of PICA with a distal aneurysm (Figures 2A and 2B).
CT brain on the second presentation. A - Intracerebral hemorrhage in the cerebellar vermis with extension into the distorted fourth ventricle, the third and lateral ventricles, the quadrilateral cistern, and the left cerebral peduncle with adjacent vasogenic edema; B - CTA showing aneurysm of the right superior cerebellar artery (arrow); C - Proximal aneurysm of right PICA (arrow).
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CT head depicted a large intracranial hemorrhage centered onto the cerebellar vermis and extending into the brainstem, ventricular system, the quadrilateral cistern, and the left cerebral peduncle, with adjacent vasogenic edema. CT angiogram revealed another proximal right PICA aneurysm and a further superior cerebellar artery aneurysm (Figures 33B, and 3C).
Photomicrograph of the vertebrobasilar circulation vessel. A - vertebrobasilar circulation artery showing diffuse lymphohistiocytic infiltrate; B - Histopathology of vertebrobasilar circulation artery showing loss of internal elastic lamina and foci of fibrinoid necrosis.
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Histological examination showed a multifocal vasculitis involving medium to large-sized arteries of the entire vertebrobasilar system (Figures 4A and 4B).