PMC7533090_01
Preoperative imaging and intraoperative view. (a) Preoperative computed tomography scan showing a massive subarachnoid hemorrhage. (b) anteroposterior view of vertebral angiography showing spindle shaped aneurysmal changes of basilar artery (BA) between the bifurcations with the superior cerebellar artery (SCA) and anterior inferior cerebellar artery (AICA). (c) intimal flap and double-lumen sign were confirmed by 3-dimentional digital subtraction angiography (3D-DSA). (d) high-resolution CT showing perforators (arrow) originating from the dissecting artery. (e) intraoperative view: superficial temporal artery (arrow) -superior cerebellar artery (arrowhead) bypass. (f) intraoperative view: BA just proximall to origin of AICA (arrow) was almost normal (arrowhead) and there were no perforators nearby. BA distal to AICA was dissected (star).
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F1
Head computed tomography (CT) on admission revealed diffuse subarachnoid hemorrhage, especially thick in prepontine cistern (Fisher group 3), complicated by hydrocephalus [Figure 1a]. Digital subtraction angiography (DSA) showed spindle-shaped aneurysmal changes of basilar artery (BA) and double-lumen sign between the bifurcations with the superior cerebellar artery (SCA) and anterior inferior cerebellar artery (AICA) [Figure 1b and c]. Furthermore, trapping the lesion might cause brainstem infarction since the high- resolution CT showed perforators originating from the dissecting artery [Figure 1d]. SCA was exposed by opening the ambient cistern, and the prepared STA was anastomosed to SCA [Figure 1e]. BA just distal to origin of AICA was almost normal and there were no perforators nearby [Figure 1f], and a clip was applied to this part.
Postoperative imaging. (a) Postoperative MRI showed an infarction. (b, c) Postoperative angiography revealed that no new aneurysm was observed in the dissecting area with sufficient blood flow to bilateral AICA (arrows) and the patency of the bypass (arrow heads) was maintained well.
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Postoperative diffusion-weighted magnetic resonance (MR) imaging showed an infarction in right midbrain which causes partial paralysis of the left limb [Figure 2a]. DSA performed on postoperative day 9 revealed no anterograde flow to the dissecting area with sufficient blood flow to bilateral AICA [Figure 2b], and the patency of the bypass was maintained well [Figure 2c].