PMC8769464_01
CT and CTA on admission. (A) CT shows subarachnoid hemorrhage and intraventricular hemorrhage, with a thick hematoma around the choroidal fissure. (B-D) CTA. The point of rupture is visualized as a high-density spot (white arrow).
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SAH (Fig. 1A). She had no hypertensive disorder of pregnancy and no past medical history of connective tissue disorders or Moyamoya disease (MMD). Source images from CTA revealed a small, hyperdense area in the hematoma around the choroidal fissure (Fig. 1B-D). Subsequent DSA and 3D rotational angiography (3DRA) showed contrast pooling at the same point (Fig. 2A and 2B), but with no obvious communication with the lesion, because the parent artery was very thin.
Cerebral angiography on day 0 and day 6. (A) DSA of the left vertebral artery (cranial 22 ) on day 0 shows a small amount of contrast pooling (white arrow), but identifying the lateral posterior choroidal artery (LPChA) itself is difficult. (B) 3D rotational angiography on day 0 clearly reveals the aneurysm (white arrow). (C) DSA of the left vertebral artery (cranial 35 ) on day 6 shows enlargement of the dissecting aneurysm and slight enlargement of the LPChA proximal to the aneurysm (white arrow). (D) Lateral view of the left vertebral artery injection. White arrow: contrast pooling.
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Source images from CTA revealed a small, hyperdense area in the hematoma around the choroidal fissure (Fig. 1B-D). Subsequent DSA and 3D rotational angiography (3DRA) showed contrast pooling at the same point (Fig. 2A and 2B), but with no obvious communication with the lesion, because the parent artery was very thin. DSA on day 6 showed enlargement of the pseudoaneurysm and relatively clear communication with the lesion (Fig. 2C and 2D), and hence, embolization was performed on day 11 (Fig. 3).
Intraoperative images. (A) DSA of the left vertebral artery (cranial 30 ) before embolization shows severe stenosis of the parent artery (white arrow) just proximal to the contrast pooling, and no branches around the lesion. (B) Cone beam CT with undiluted contrast medium shows a tortuous lateral posterior choroidal artery (LPChA) (white arrow) proximal to the aneurysm. (C) Control left vertebral angiography after embolizing the aneurysm and LPChA. The left posterior cerebral artery (PCA) is difficult to see because of the microcatheter. (D) Injection from the microcatheter performed just after obtaining image C shows contrast medium extravasation. (E) Control left vertebral angiography after occlusion of the left PCA. Platinum coils are seen in both the LPChA and main trunk of the PCA. (F) Final control DSA of the left vertebral artery (cranial 30 ). The main trunk of the left PSA is not evident.
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DSA during embolization showed severe stenosis of the parent artery just proximal to the contrast pooling and absence of arterial branches around the lesion (Fig. 3A). Braun, Melsungen, Germany), but the microcatheter could not be inserted into the LPChA because of the tortuous course (Fig. 3B). We then changed the microcatheter to a firmer one, followed by coil embolization of the dissection and the LPChA (Fig. 3C). DSA just after embolization of the dissection and LPChA showed contrast extravasation (Fig. 3D). Hence, additional coils were placed and occlusion of the main trunk of the posterior cerebral artery was needed to completely stop the extravasation (Fig. 3E and 3F).
Pre- and post-procedure diffusion-weighted images (DWI). (A and B) Preoperative DWI on day 0 shows hyperintensity around the choroidal fissure, including the hippocampus. (C and D) DWI on postoperative day 2 shows new ischemic lesions in the occipital and medial temporal lobes.
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Diffusion-weighted imaging performed 2 days after the procedure showed new hyperintense lesions in the left medial temporal and occipital lobes (Fig. 4).