Abstract
Objective: We report the case of bilateral vertebral artery dissection (VAD) with subarachnoid hemorrhage diagnosed by vessel wall imaging (VWI).
Case Presentation: A 56-year-old man had suffered from sudden onset of a mild headache 2 days before admission. He was diagnosed with subarachnoid hemorrhage. Conventional angiography showed irregular dilatation on V4 segment of bilateral vertebral artery, both of which were suspicious of arterial dissections. Identification of the ruptured side was difficult by the angiographic appearance as both dilatations were comparable, and MRA failed to detect either the intimal flap or double lumen sign. Fortunately, VWI by GdT1-SPACE demonstrated enhancement along the vessel wall in both lesions, and intimal flap was also observed in the right side, confirming the diagnosis of bilateral VAD. MRA on Day 1 showed the worsening of right VAD, while no morphological changes were observed in the contralateral side. Thus, the right VAD was considered the ruptured side, and we performed proximal occlusion of the right VA in endovascular, preserving the right posterior inferior cerebellar artery (PICA) by the retrograde flow via contralateral VA. MRA on Day 5 showed the stenosis of left VA; therefore, systemic administration of heparin was applied to prevent the thrombotic occlusion of left VA. Finally, the resolution of the stenosis was confirmed in Day 13, and he was discharged in Day 34 with modified Rankin Scale score of 1.
Conclusion: VWI appears useful for the diagnosis of VAD even in difficult cases such as bilateral lesions.
