Cerebellar Infarction Following Pulseless Electrical Activity Arrest in Advanced Heart Failure With Reduced Ejection Fraction: A Post-resuscitation Diagnostic Pitfall

Background:Cerebrovascular events are a potentially serious complication of giant cell arteritis (GCA) with intracranial involvement. However, diagnosing GCA in this context remains challenging, as classical clinical features may be absent.Objectives:To identify characteristic cerebellar infarct patterns associated with intracranial GCA and to differentiate them from other common causes of posterior circulation stroke.Design:Multicenter retrospective study.Methods:A total of 125 patients with cerebellar infarctions of various etiologies were included. Among these, 19 patients had confirmed intracranial GCA. Infarct patterns were compared to those seen in strokes of cardioembolic origin (n = 42), arterio-arterial embolism from proximal vertebral artery atherosclerosis (n = 13), local atherosclerotic stenosis of the V4 segment (n = 21), and vertebral artery dissection (n = 30). Infarct topography was assessed using acute-phase diffusion-weighted magnetic resonance imaging. Sensitivity and specificity were calculated for individual imaging features.Results:Distinct imaging signatures were observed in patients with GCA. A “corona-like” infarct pattern, defined by sparing of the medial branch of the proximal posterior inferior cerebellar artery (PICA), demonstrated a sensitivity of 79% and a specificity of 64%. A patchy infarct pattern, characterized by scattered non-confluent lesions, was present in 53% of GCA cases and showed high specificity (93%). When both features were present, specificity increased to 98% and sensitivity was reduced to 47%.Conclusion:Our findings reveal a distinct cerebellar infarct pattern associated with intracranial GCA, characterized by a corona-like configuration and patchy lesions predominantly involving the lateral PICA territory. Recognition of this imaging phenotype may enhance diagnostic accuracy in challenging cases and facilitate the timely initiation of immunosuppressive therapy.

BackgroundDizziness is a frequent complaint among elderly patients with acute ischemic stroke. However, its association with different grades and locations of arterial stenosis remains unclear. This study aimed to assess the links between stenosis severity, posterior circulation involvement, dizziness, and short-term neurological outcomes.MethodsA retrospective analysis was performed on 134 elderly patients with acute ischemic stroke admitted from January 2024 to May 2025. All patients underwent Computed Tomography Angiography (CTA) or MRA of the intracranial and extracranial arteries, including the common and internal carotid arteries, the middle cerebral artery, the vertebral artery (VA), and the basilar artery (BA). Stenosis of extracranial segments was measured with North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, while intracranial segments were assessed using Warfarin–Aspirin Symptomatic Intracranial Disease Trial (WASID) standards. Patients were grouped by the most severely affected major supplying artery as mild (<50%), moderate (50–69%), or severe (≥70% or occlusion) stenosis. A separate vertebrobasilar artery (VA/BA) stenosis group included individuals with ≥50% stenosis of the vertebral or BA, regardless of anterior circulation status. Collected data included baseline characteristics, dizziness occurrence, Dizziness Handicap Inventory (DHI) scores, admission National Institutes of Health Stroke Scale (NIHSS) scores, and 3-month modified Rankin Scale (mRS) scores. Univariate and multivariate logistic regression analyses were conducted to identify risk factors.ResultsThe severe stenosis group and the VA/BA stenosis group showed higher dizziness rates than the other groups (44.9 and 50.0%, p < 0.01). Cerebellar and brainstem infarctions were more frequent in patients with VA/BA stenosis (83.3%), and these infarcts also appeared more often in the dizziness group (65.8% vs. 19.8%). Multivariate analysis indicated that VA/BA stenosis (OR = 3.42, 95% CI: 1.28–9.13) and posterior circulation infarction (OR = 4.51, 95% CI: 2.01–10.13) were independent factors related to dizziness. Severe stenosis (OR = 4.96) and VA/BA stenosis (OR = 3.18) were independently associated with functional dependence at 3 months (mRS ≥ 3). Admission NIHSS (OR = 1.42) and age (OR = 1.10) also suggested poorer outcomes.ConclusionIn elderly patients with acute ischemic stroke, severe arterial stenosis and VA/BA stenosis were linked to higher risks of dizziness and 3-month functional dependence. Posterior circulation infarction markedly increased the likelihood of dizziness. Enhanced vascular imaging assessment and attention to symptoms such as dizziness may help identify high-risk individuals and support personalized management.

This case details the diagnostic challenge of ANCA-negative granulomatosis with polyangiitis (GPA) initially presenting as refractory chronic rhinosinusitis, mimicking recurrent infections, and other granulomatous conditions. It highlights the potential for significant diagnostic delay when serological markers are absent. A 65-year-old female with recurrent sinusitis underwent multiple antibiotic regimens and endoscopic sinus surgery. Despite this, she developed progressive destructive manifestations over 10 months: nasal septal perforation, saddle nose deformity, keratouveitis with exophthalmos, macrohematuria, and a lacunar cerebellar infarct. Serial microbiology showed various pathogens; histology initially suggested rhinoscleroma. ANCA remained negative. Following the clinical diagnosis of ANCA-negative GPA, therapy with rituximab and corticosteroids was initiated, leading to significant improvement and sustained remission on maintenance immunosuppression. This case demonstrates that ANCA-negative GPA can present as refractory sinonasal disease. Negative serology does not exclude GPA; a high clinical suspicion is warranted in cases with destructive features and systemic progression. Early immunosuppressive treatment is essential to prevent severe organ damage.

Catastrophic antiphospholipid syndrome (CAPS), also known as Asherson’s syndrome, is a rare and life-threatening condition that represents the most severe clinical manifestation of antiphospho lipid syndrome. Due to its rapid and aggressive course, CAPS is characterized by the development of widespread micro- and macrothrombosis, which results in multi-organ ischemia and failure. Antiphospholipid syndrome, an autoimmune disorder, is characterized by thrombotic and/or obstet ric events, accompanied by persistent antiphospholipid antibodies. The case of a 36-year-old woman was described, who initially presented with low-effort dyspnea and abdominal pain, with subsequent imaging revealing pulmonary embolism and aortic thrombosis, alongside acute ischemic cerebellar infarcts. The eventual confirmation of a positive lupus anticoagulant solidified the diagnosis of CAPS. This case underscores the diagnostic challenge posed by CAPS, particularly when presenting with prominent pulmonary embolism, and highlights the critical need for prompt recognition and mul tidisciplinary management. Furthermore, the patient’s positive outcome demonstrates the potential for recovery even in such severe presentations. Cite this article as: Maradiaga FA, Diaz VS, Rubio MA, Arias JP, Alas-Pineda C. A case of catastrophic antiphospholipid syndrome presenting as pulmonary embolism and renal thrombosis: a case report and literature review. Eur J Rheumatol. 2025, 12(4), 0018, doi:10.5152/eurjrheum.2025.25018.

Cervical artery dissection and patent foramen ovale (PFO) are relevant causes of ischemic stroke (IS)in young adults. We report the case of a 35-year-old previously healthy man who presented with severevertigo, gait ataxia, and bradycardia, later diagnosed with cerebellar infarction secondary to bilateralvertebral artery dissection. Further investigation revealed the presence of a PFO. This case underscoresthe importance of thorough etiological investigation of IS in young adults, focusing on the identificationof cervical artery dissections and structural cardiac abnormalities as risk factors.

To evaluate the efficacy and safety of external ventricular drainage (EVD) in managing patients with space-occupying cerebellar infarction.The 48 patients were divided into two groups: the EVD group and the non-EVD group. The outcomes of the patient were assessed using the modified Rankin Scale (mRS), with scores of ≤ 3 indicating a favorable prognosis.Among the 48 patients, 29 underwent EVD, while 19 were in the non-EVD group. This non-EVD group included 14 patients who underwent suboccipital decompression and 5 who underwent suboccipital decompression combined with necrosectomy. In the EVD group, 20 patients had a favorable prognosis and 9 had a poor prognosis, with 6 deaths. In the non-EVD group, 16 patients had a favorable prognosis and 3 had a poor prognosis, with 3 deaths. No statistically significant differences were observed between the two groups. Multivariate logistic regression analysis revealed that a Glasgow Coma Scale (GCS) score < 9 (OR 9.5, 95% CI 1.5-77.0, P = 0.05), cerebral infarction (OR 15.6, 95% CI 2.3-144.0, P = 0.03), and the requirement for postoperative ventilatory support (OR 12.7, 95% CI 2.7-79.4, P = 0.01) were independent risk factors for poor patient outcomes.For patients with space-occupying cerebellar infarction, EVD might be an effective and safe treatment option. However, its efficacy and safety require further confirmation through prospective randomized clinical trials.

Nontraumatic cases of impaired/altered sensorium continue to be one of the most frequent emergencies that casualties encounter. The patient's overall prognosis may depend on early clinical evaluation and etiological diagnosis. In order to make a more accurate and timely diagnosis, it is crucial to understand the etiological profile of comatose patients who arrive at a tertiary care facility, which can successfully predict the outcome. This prospective observational study was carried out in a South Indian tertiary care facility. A total of 126 patients with altered mental status of nontraumatic origin who arrived at the emergency room with Glasgow coma scale (GCS) scores below 10 were included in the study. Of the 126 patients, 48 (38.1%) were female and 78 (61.9%) were male. All patients were 52.65 ± 17.94 years old on average. The comorbidities observed in this study were hypertension (49.2%), diabetes mellitus (36.5%), alcoholism (33.3%), smoking (25.3%), coronary artery disease (CAD) (7%), chronic kidney disease (CKD) (9.5%), epilepsy (4.7%), and previous cerebrovascular accident (CVA) (9.5%). The presenting symptoms other than altered sensorium were fever (4%), vomiting (9.5%), headache (3%), motor weakness (16%), seizures (15.8%), and breathlessness (4.7%). About 36 patients (28.5%) had abnormal neurological examination, with motor weakness being the most common finding in 34 patients (27%). A brain magnetic resonance imaging (MRI) or computed tomography (CT) scan was performed on 104 patients (82.5%), and 50 patients (48%) had abnormal results. The commonest finding was cerebral and cerebellar infarction seen in 35 patients (33.6%). A number of 48 (38%) patients had abnormal electrocardiogram (ECG), 42 (33%) had nonspecific ischemic alterations, and six patients (4.7%) had atrial fibrillation. In our study, 46 patients (36.5%) had neurological causes of impaired/altered sensorium, 32 patients (25.4%) had metabolic causes, 18 patients (14.3%) had multifactorial causes, 14 patients (11.1%) had infections, and 16 patients (12.7%) had other causes [status epilepticus, drug overdose, organophosphate (OP) poisoning]. The commonest neurological cause was ischemic stroke, noted in 32 patients (69.5%), out of which 16 cases were posterior circulation strokes. About 14 cases had anterior circulation stroke. The remaining two cases presented with both anterior and posterior circulation strokes. The mortality rate was 36.5%. A number of 46 patients died out of 126 patients. Out of 46 patients, CVA was the most common cause of death, accounting for 20 cases (43.4%). In this study, the duration of altered mental status, GCS score, level of altered consciousness, and etiology were found to be significant prognostic markers that correlated with outcome in nontraumatic cases with impaired/altered sensorium. Factors that offer early prognostic information can help with resource allocation decisions because the cost of intensive care has increased significantly. The prognosis can be predicted using a simple clinical evaluation of neurological function, paying particular attention to the degree of consciousness, focal neurological signs, and brainstem reflexes.

Background: Cerebellar infarction complicated by obstructive hydrocephalus is a life-threatening condition. External ventricular drainage (EVD) has traditionally been regarded as hazardous due to concerns about precipitating upward transtentorial herniation, whereas suboccipital decompressive craniectomy (SDC) remains the definitive life-saving treatment. The optimal role and sequencing of these interventions remain controversial. Methods: A scoping review was conducted in accordance with PRISMA-ScR guidelines. PubMed/MEDLINE was systematically searched from inception to September 2025. Eligible studies included adult patients with cerebellar infarction and acute obstructive hydrocephalus managed with EVD, with or without SDC. Data on study design, patient characteristics, interventions, complications, and outcomes were extracted and narratively synthesized. Results: Forty studies were included, encompassing multicenter registries, retrospective cohorts, case series, and international guidelines. Evidence suggests that EVD alone can be effective in selected patients with preserved or moderately impaired consciousness, while outcomes in comatose patients are improved with SDC or combined approaches. Importantly, this scoping review integrates current evidence with a representative institutional case to provide a practical clinical context. Radiographic signs of upward transtentorial herniation before EVD were common, but clinically significant deterioration was infrequent. Prognostic factors for surgical decision-making included infarct volume (practical threshold 25-35 mL), location (vermian or bilateral infarcts), brainstem involvement, and level of consciousness. International guidelines increasingly recognize EVD as a valid treatment option, particularly as initial therapy for hydrocephalus. Conclusions: EVD should no longer be regarded as an absolute contraindication in cerebellar infarction with obstructive hydrocephalus. Controlled drainage can suffice in carefully selected patients, whereas SDC remains indispensable in cases with severe mass effect or brainstem compression. A pragmatic stepwise approach-beginning with cautious EVD and escalating to SDC when indicated-may optimize outcomes. Further multicenter studies are required to refine patient selection criteria and establish standardized management algorithms.

Network pharmacology is instrumental in understanding how TCM works by targeting specific pathways. This study examines different mechanisms using three network pharmacology approaches, focusing on the TCM "Bai Mi Decoction" (BMD). The neuroprotective effects of BMD were evaluated in a middle cerebral artery occlusion-reperfusion (MCAO/R) rat model. The composition of BMD extract (BMDE) and its components in brain (BMDB) were analyzed using UHPLC-QTOF-MS/MS, alongside documented constituents from the database (BMDD). A network pharmacological analysis was conducted to explore the similarities and differences in BMD's neuroprotective mechanisms. BMD showed a strong neuroprotective effect in MCAO/R rats, as indicated by lower neurological deficit scores, smaller cerebellar infarct sizes, and improved histopathological changes. Analysis identified 45, 11, and 22 components in BMDE, BMDB, and BMDD, respectively, with 29, 26, and 23 potential therapeutic targets. However, most database-listed compounds were not found in actual samples. Functional enrichment and pathway network analysis showed that BMDE and BMDB shared the most targets. MAPK1 was the only common target across all groups, targeted by crocetin, the sole shared compound. BMD proved highly effective in MCAO/R rats, with compounds found in BMD extracts or invivo better reflecting the actual pharmacological mechanisms than database-derived ones.

Posterior inferior cerebellar artery infarction right secondary to occlusion probably dissection Shogun Pillow Syndrome: A case report

Management of large cerebellar infarctions with potential malignant evolution is highly heterogeneous across physicians, and recommendations rely on low-evidence studies. We aimed to perform a systematic review and meta-analysis on patients with large cerebellar infarction undergoing neurosurgery, to study mortality and functional outcome, according to neurosurgical technique. We searched on PubMed and Embase according to pre-defined selection criteria and we assessed their quality according to a predefined risk of bias scale. Our primary outcomes were mortality and functional outcome rates. Favorable outcome was defined as a modified Rankin scale of 0-2, a Glasgow Outcome Scale of 4-5, or a Barthel Index > 90%. Pooled rates were obtained using random effect model and heterogeneity was quantified using I2 statistics. Among 27 included studies (including 1173 patients), we studied the 662 patients undergoing neurosurgery. All studies were retrospective and observational; there was no randomized clinical trial (RCT). The median selection bias score was 5 (IQR, 4-6). Mortality rate was estimated at 18% [95% CI, 13-24%], I2 58%. Among survivors, 64% achieved a favorable functional outcome [95% CI, 51-77%], I2 82%. Study design and heterogeneity in patients' characteristics limited a meaningful comparison of mortality and functional outcome according to neurosurgical techniques. High-quality evidence on neurosurgical treatment for large cerebellar infarctions remains limited. Our systematic review and meta-analysis, despite moderate risk of bias, suggest that neurosurgery may reduce mortality and improve functional outcomes. These findings support its potential benefit, but RCTs are needed to confirm effectiveness and evaluate best surgical technique.

Background/Objectives: Superior cerebellar artery (SCA) infarction is a rare but clinically significant subtype of posterior circulation stroke. Extensive swelling in the SCA territory may cause downward brainstem compression and appear as brainstem hypodensity on computed tomography, potentially leading to premature treatment withdrawal. Methods: We report the case of a 50-year-old woman with acute SCA-territory infarction (NIHSS = 7) presenting with vertigo, dysphagia, dysarthria, and diplopia. Initial computed tomography suggested extensive brainstem infarction, prompting withdrawal of treatment. Diffusion-weighted MRI revealed reversible edema with brainstem sparing. The patient underwent suboccipital decompressive craniectomy and ventricular drainage with favorable neurological recovery. In addition, a systematic literature search was conducted according to PRISMA 2020 guidelines in PubMed, Web of Science, and Scopus (studies published since 1 January 2015). Fifteen studies met predefined eligibility criteria. Results: Magnetic resonance imaging findings were decisive in avoiding a falsely dismal prognosis and inappropriate withdrawal of care. Across the literature, infarct volume (>30-35 mL), brainstem involvement and bilateral cerebellar infarction emerged as key predictors of malignant course. Early decompressive surgery was consistently associated with improved survival, though functional outcomes varied. Fast magnetic resonance imaging techniques and volumetric imaging improved risk stratification and surgical decision-making. Conclusions: SCA infarction can mimic brainstem infarction on computed tomography due to secondary compression rather than true ischemia. Magnetic resonance imaging is essential to guide treatment and prevent avoidable mortality. Multimodal imaging combined with interdisciplinary management allows for accurate prognostication and optimized surgical timing in malignant SCA infarction.

PurposeAccurate identification of computed tomography (CT) perfusion ischemic core in patients with basilar artery occlusion (BAO) on admission remains challenging despite its critical role in prognostic prediction and treatment decision-making. We aimed to define the optimal threshold for identifying the ischemic core by assessing agreement in lesion extent and spatial distribution using Syngo.via.MethodsWe retrospectively analyzed 91 patients with BAO who achieved successful recanalization after endovascular thrombectomy at our center. The ischemic core was estimated using the following thresholds: cerebral blood flow (CBF) < 10 or 15 mL/100 g/min by Syngo.via, cerebral blood volume < 1.2 mL/100 mL by Syngo.via, and time to maximum > 10 s by RAPID. The Posterior Circulation Alberta Stroke Program Early CT Score was used to assess the extent of the infarction. Statistical analyses included the intraclass correlation coefficient (ICC) and receiver operating characteristic analyses.ResultsThe CBF < 10 mL/100 g/min threshold demonstrated good agreement in extent with follow-up infarction (ICC: 0.81 [95% confidence intervals 0.72–0.87]), with overestimation or underestimation being the most uncommon (n = 9). For the detection of midbrain, pontine, and cerebellar infarction, this threshold yielded the best performance with the area under the curve ranging from 0.79 (midbrain, 0.66–0.93; p < 0.001) to 0.90 (pons, 0.83–0.98; p < 0.001).ConclusionIn patients with BAO after successful recanalization, the optimal threshold for the ischemic core was a CBF < 10 mL/100 g/min. This threshold may serve as a reliable imaging biomarker, aiding in the prediction of tissue outcomes and treatment decision-making.

Background:Recent guidelines do not clearly favor either conservative or surgical treatment for cerebellar infarction. We aim to compare the clinical outcomes of these 2 treatments in patients with cerebellar infarcts through meta-analysis.Methods:We systematically searched 4 databases – PubMed, Cochrane Library, Embase, and Web of Science – from inception to May 1, 2024 to identify eligible studies that compared surgical treatment and conservative treatment. Two authors independently extracted data on mortality, modified Rankin Scale, and Glasgow outcome scale for patients with cerebellar infarction.Results:We retrieved 12 eligible studies, including 1108 participants. No significant differences were observed in terms of mortality, modified Rankin Scale, acute cerebellar infarction between the 2 treatments. However, there was a statistically significant difference between surgery and no-surgery group regarding serious adverse outcomes with a Glasgow outcome scale score of 2 to 4, including moderate recovery, severe disability, persistent vegetative state (odds ratio: 2.14; 95% confidence interval: 1.05–4.36; P = .04; I2 = 0%), and in the consciousness dysfunction group (odds ratio: 0.32; 95% confidence interval: 0.12–0.88; P = .03; I2 = 64%).Conclusion:This meta-analysis of cohort studies indicated that surgery led to more serious adverse outcomes for patients with cerebellar infarction compared to conservative treatment, but showed more favorable outcomes for patients with consciousness dysfunction during follow-up. Further research is warranted to explore these aspects in depth.

Background: Adult-onset Still’s disease (AOSD) is a rare autoinflammatory condition characterized by severe systemic inflammation and multi-organ involvement. While pulmonary hypertension (PH) is an uncommon complication of AOSD, intracardiac thrombi are exceedingly rare. To our knowledge, this is the first reported case involving concurrent PH and intracardiac thrombosis in AOSD. Case: A 27-year-old female with recurrent fevers, arthralgias, an evanescent rash, and hyperferritinemia (10,661 ng/mL) was diagnosed with AOSD following an initial presentation of macrophage activation syndrome (MAS). She improved with anakinra and corticosteroids. Months later, she was readmitted with fever and hypotension requiring vasopressors. Infectious workup was negative, and recurrent MAS was diagnosed. Transthoracic echocardiography revealed severe PH and a mobile right atrial thrombus, initially suspected to be central-line associated; the central line was subsequently removed. She responded to intensified immunosuppressive therapy. Days later, she developed headaches and seizures. Brain MRI showed posterior vasogenic edema concerning for posterior reversible encephalopathy syndrome (PRES), likely related to immunosuppression. Her condition rapidly deteriorated with severe headache and bilateral fixedly dilated pupils. Imaging revealed bilateral cerebellar infarctions with hemorrhagic conversion and tonsillar herniation, prompting emergent suboccipital craniectomy and external ventricular drain placement. A follow-up transesophageal echocardiogram identified two large (&gt;2 cm) right atrial thrombi, one highly mobile, indicating persistent thrombosis despite line removal. Agitated saline contrast confirmed a patent foramen ovale with right-to-left shunting. Decision-Making: Given recent intracranial hemorrhage, anticoagulation was contraindicated. Due to the risk of embolization and obstruction, she underwent successful percutaneous AngioVac-assisted thrombectomy. She was also treated with emapalumab targeting interferon-γ to control systemic hyperinflammation. Conclusion: This case illustrates a rare and complex cardiovascular complication of AOSD—intracardiac thrombi in the setting of PH and hemorrhagic stroke. It highlights the role of mechanical thrombectomy when anticoagulation is not feasible and underscores the importance of early multidisciplinary intervention in critically ill patients with severe autoinflammatory disease.

Introduction Rotational occlusion of the vertebral artery, known as Bow Hunter's Syndrome, is a rare but recognized cause of transient neurological symptoms due to dynamic vascular compression during head rotation. While typically associated with positional vertigo or dizziness, it can occasionally lead to vertebrobasilar ischemia and infarction. We present 2 unique cases of recurrent posterior circulation strokes due to compression of the same vertebral artery segment, highlighting the diagnostic importance of dynamic vascular imaging. Case Description: Case 1 A female in her 50s with ADHD, chronic migraines, and cervical spine pathology (status post C3‐T2 posterior fusion and C4‐C7 anterior discectomy) presented with sudden‐onset headache, blurry vision, and dizziness. CTA showed occlusion of the right vertebral artery at C3‐C4 with distal reconstitution, initially interpreted as chronic. MRI revealed bilateral cerebellar infarcts, right &gt; left. RCVS was considered given Vyvanse use, but DSA showed no vasospasm, and the artery had spontaneously recanalized. Further workup revealed a PFO and positive JAK2 mutation. She underwent PFO closure and was discharged on aspirin. Six months later, she re‐presented with left facial droop, left‐sided weakness, and right gaze preference. She received TNK and was admitted. MRI showed multifocal infarcts in the right &gt; left cerebellum, right thalamus, and midbrain. MRA showed recanalization of the right vertebral artery with features suggestive of intramural hematoma consistent with dissection. Repeat DSA with head maneuvers demonstrated dynamic, flow‐limiting stenosis of the right V3 segment, worsened with leftward and upward head positioning. Imaging identified a chronic odontoid fracture with posterior displacement. Neurosurgery deferred intervention, opting for follow‐up after healing of the dissection. The patient was managed conservatively with dual antiplatelet therapy, neck bracing, and avoidance of provocative neck movements. Case 2 A female in her 70s with hyperlipidemia, hypothyroidism, and diabetes mellitus established care in 2023. She reported episodic dizziness since a presumed TIA in 2021. In 2022, she had an acute left cerebellar and occipital infarct, plus chronic infarcts in the left PICA territory and anterior circulation. Imaging revealed a hypoplastic left vertebral artery with compression at the V2 segment. A loop recorder remained unremarkable. In July 2024, she developed new subacute bilateral occipital infarcts. CTA showed persistent occlusion of the left V3 segment. Given recurrent strokes without cardioembolic source, antiplatelet therapy was switched to anticoagulation. Follow‐up CTA after two months showed spontaneous recanalization, raising concern for intermittent compression. DSA with head positioning revealed positional occlusion of the left vertebral artery at C3 transverse foramen when the head was neutral or turned left, and reconstitution with the head turned right. She underwent C2‐C5 laminectomy and posterior cervical fusion. Discussion In patients with recurrent posterior strokes and spontaneous vertebral artery recanalization, dissection should be suspected. DSA with provocative maneuvers is critical to identify dynamic compression and delineate the injury mechanism. No consensus on optimal management. Both DAPT and anticoagulation are used, often guided by protocols, patient‐specific factors, and recurrence risk. These cases underscore the importance of recognizing cervical pathology as a precipitant of dynamic vascular injury.

Introduction/Purpose Posterior circulation aneurysms account for 10‐15% of unruptured intracranial aneurysms and are more prone to rupture than those of anterior circulation. Giant basilar artery aneurysms pose significant risk as 80% of symptomatic patients become severely disabled or die within 5 years at a 50% five‐year rupture rate. Complications, including cranial neuropathies, hydrocephalus, quadriparesis, and respiratory failure, are related to local mass effect. Neurointerventional device limitations and their unique anatomy restrict conventional flow diversion, open surgical access, or parent vessel reconstruction. In this report, we highlight the novel management of a giant basilar artery aneurysm with deconstructive vertebral artery (VA) sacrifice and VA‐to‐VA pipeline embolization. Materials/Methods Case report. Results/Case Description An elderly male with hypertension and tobacco use presented with vomiting and dizziness. CTA revealed a 22mm basilar artery aneurysm. Angiogram revealed a giant, nearly‐completely thrombosed, complex neck semisaccular basilar aneurysm between the vertebrobasilar junction and AICAs. It exceeded flow diverter diameters and was not treated. He developed quadriplegia, dysphagia, and respiratory failure. MRI revealed aneurysmal enlargement with partial thrombosis, brainstem and fourth ventricular compression, and hydrocephalus. He required VPS, tracheostomy, and gastrostomy. Repeat angiogram demonstrated near‐complete aneurysmal thrombosis and bilaterally patent PICAs. He underwent right distal VA coil embolization as a pre‐operative adjunct to aneurysm clipping. Deemed a high‐risk neurosurgical candidate, he was instead discharged and re‐admitted 1‐month post‐embolization to evaluate treatment efficacy with a repeat angiogram. Despite coiling, the aneurysm had grown with partial recanalization and associated progressive brainstem edema. VA‐to‐VA pipeline embolization was performed by placing 3 pipeline embolization devices from the right V4 to the left V4 across the vertebrobasilar junction with collateral flow to the distal posterior circulation via the right PICA. Post‐operative course included cerebellar and occipital infarcts. Conclusion This report is, to our knowledge, the first VA‐to‐VA pipeline embolization for the management of a giant basilar artery aneurysm. Growth despite aneurysmal thrombosis and hydrocephalus requiring VPS remain under‐appreciated complications of these aneurysms. image

Introduction Aneurysms of the posterior fossa, in particular the posterior inferior cerebellar artery (PICA), are rare and technically challenging lesions to treat due to their eloquent location and complex morphology. Traditional microsurgical and endovascular approaches have provided varying results over the years. Flow‐diverting stents (FDS), particularly newer‐generation devices like the Pipeline Vantage with Shield Technology, offer a promising alternative in select cases Methods We present a case series of three patients with PICA aneurysms treated with the Pipeline Vantage 021 Embolization Device. One patient had a ruptured proximal PICA aneurysm treated with staged endovascular therapy after stabilization. The remaining two patients had incidentally discovered unruptured proximal PICA aneurysms and underwent elective flow diversion. All patients received dual antiplatelet therapy and underwent interval follow‐up digital subtraction angiography. Results All three cases resulted in technically successful deployment of the Pipeline Vantage 021 device, with no intraprocedural complications. One patient experienced a delayed cerebellar infarction but recovered well with no long‐term deficits. Follow‐up angiography after 6 months demonstrated complete aneurysm obliteration in all cases. One patient developed moderate in‐stent stenosis without clinical symptoms. No cases of braid deformation, rebleeding, in‐stent thrombosis, or delayed aneurysm rupture were observed. Conclusions Our early experience supports the safety and efficacy of the Pipeline Vantage 021 flow diverter in treating PICA aneurysms, including ruptured and unruptured lesions. This series adds to the limited literature supporting flow diversion in the posterior circulation and highlights the importance of patient selection, periprocedural management, and close follow‐up. image

Rationale:This case report describes a rare instance of concurrent acute cerebellar and spinal cord infarction caused by right vertebral artery occlusion, providing dynamic angiographic visualization of the collateral circulation.Patient concerns:A 69-year-old male with hypertension and diabetes presented with thunderclap occipital headaches, left-dominant limb hypesthesia, and mild bladder dysfunction.Diagnoses:Brain magnetic resonance imaging revealed an acute right cerebellar infarction in the posterior inferior cerebellar artery (PICA) territory. Cervical magnetic resonance imaging demonstrated bilateral anterior horn hyperintensity (“owl’s eye” sign) at C2 to C4, consistent with spinal cord infarction. Digital subtraction angiography confirmed atherosclerotic occlusion at the right vertebral artery origin, with collateral circulation via the deep cervical artery. Cerebrospinal fluid analysis showed elevated protein (0.679 g/L) without pleocytosis or autoantibodies (AQP4/MOG/MBP), excluding inflammatory/demyelinating etiologies.Interventions:The patient was treated with antiplatelet therapy (aspirin) and statins (rosuvastatin).Outcomes:The patient’s symptoms significantly improved within 2 weeks (headache Visual Analog Scale score decreased from 8 to 2).Lessons:This is the first reported case combining acute cerebellar (PICA territory) and cervical spinal cord (C2–C4) infarction, with digital subtraction angiography visualization of collateral circulation via the deep cervical artery. It underscores vertebral artery occlusion as a rare yet critical cause of dual cerebellar–spinal infarction, mediated by hemodynamic compromise in both PICA and anterior spinal artery territories.