Recently, BPAS, which can visualize the surface appearance of the vertebrobasilar artery system within the cistern, has been used for the diagnosis of arterial dissection, however, it cannot identify the PICA in some cases. In the case of ischemic stroke, however, MRA is prioritized, and due to the inability of MRA to depict most of the normal PICA, PICA-D is likely to be overlooked. As an initial clinical presentation, a subarachnoid hemorrhage is the most common clinical entity following PICA-D, and a cerebral angiogram is performed early in most cases. PICA-D complicated with ischemic stroke is rare. In these cases, T1-VISTA helped us for the diagnosis and follow-up of PICA-D. Dilatation gradually normalized on MRA and the high-intensity signal area on T1-VISTA gradually reduced and disappeared at 4 months after the onset (Fig. At 8 days after the onset, cerebral angiography demonstrated the “pearl and string sign” at the proximal portion of the left PICA (Fig. Since her blood pressure was not high, we even didn’t use antihypertensive treatment. Three days later, the dilated portion was enlarged on MRA, therefore, we discontinued unfractionated heparin administration. According to these findings, Ischemic stroke of the cerebellum caused by dissection of the left PICA was diagnosed, and the administration of unfractionated heparin was started. Cardioembolic causes were excluded by echocardiography and 24-hour electrocardiography. Conventional T1 image was obtained on admission and at 24 days after admission, but no high-intensity area was observed at both time points. T1-VISTA showed a high-intensity signal area at the dilated portion (Fig. The proximal portion of the left PICA was not visualized, and the adjacent distal portion appeared to be dilated on MRA (Fig. In addition, the external diameter of the left VA on basiparallel anatomic scanning (BPAS) was narrowed, suggesting hypoplasia. The left VA was poorly visualized on MRA as compared to the right VA (Fig. MRI was then performed at 4 days after the onset, which showed an acute infarction in the left cerebellar hemisphere (Fig. Neurologically, she presented only mild dizziness. Although no abnormalities on a physical examination or in laboratory data were observed, her nausea and dizziness persisted. Head CT showed no abnormal findings, thus she was admitted under the suspicion of acute drug poisoning by a detergent. Clopidogrel administration was then stopped.Ī 52-year-old woman suddenly experienced vertigo and vomited while cleaning her bathtub at home and was subsequently transferred to our hospital by an ambulance. In parallel with that, the high-intensity signal area on T1-VISTA gradually decreased in size and disappeared by 5 months after the onset (Fig. Thereafter, the right PICA was gradually depicted on MRA and completely visualized at 5 months after the onset. On T1 images, a pale high-intensity area was documented at the dissected lesion at 19 days after admission. At 12 days after admission, the patient was discharged with single antiplatelet therapy (clopidogrel). At 9 days after admission, cerebral angiography revealed the “pearl and string sign” at the proximal portion of the right PICA (Fig. T1-VISTA showed a slight expansion of the high-intensity area at 3 days after admission, but still no lesions on T1 images.
According to these findings, ischemic stroke of the cerebellum induced by the right PICA-D was diagnosed, and after confirming that she had neither hypertension nor aneurysmal formation, combined therapy with clopidogrel and unfractionated heparin administration was started. Echocardiography and 24-hour electrocardiography showed no findings suggestive of cardioembolic causes. Conventional MRA did not depict the right PICA or any abnormal findings of the right VA (Fig. 1b), whereas no such high intensity was detected on conventional T1 image. In addition, a high-intensity signal area was observed just adjacent to the right VA on T1-VISTA (Fig. Head computed tomography (CT) showed low-density areas in the right cerebellar hemisphere, diffusion weighted imaging (DWI) of magnetic resonance imaging (MRI) displayed high-intensity signal areas in the cerebellar vermis and the right cerebellar hemisphere (Fig. Coagulation studies and immunological studies were normal. In peripheral blood cell counts and biochemical studies, elevations in white blood cells (9,200/μl) and low-density lipoprotein cholesterol (215 mg/dl) were observed. She showed nystagmus and the right nose-finger-nose test was positive. On admission, she complained of dizziness and a mild occipital headache. A 56-year-old woman began to suffer from an occipital headache for 7 days before admission to our hospital, and dizziness appeared 5 days later.
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