# March 2022

- Link: https://isnr.in/march-2022/
- Published: 2022-03-01T09:38:11+05:30
- Author: ISNR

## March 2022

**CASE HISTORY**:

• 23-year female patient presented with history of right sided headache since 1-
year with recent onset giddiness and occasional vomiting for 2 months. She has right
eye vision loss since birth.

• Neurological examination was normal, except perception of light positivity in 
right eye

## **Case contributed by –**

• Dr. Priyanka Priyadarshini Baishya– Senior Resident

• Dept Of Neuroimaging and Interventional Radiology, NIMHANS Bengaluru.

• Dr. Jitender Saini –Professor

• Dept Of Neuroimaging and Interventional Radiology, NIMHANS Bengaluru.

| [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar1.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar2.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar3.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar4.jpg) | 
| [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar5.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar6.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar7.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar8.jpg) | 
| [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar9.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar10.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar11.jpg) | [⌊Mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/Mar12.jpg) |

| [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar1.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar2.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar3.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar4.jpg) | 
| ⌊Answer15mar2022⌉ | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar6.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar7.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar8.jpg) | 
| [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar9.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar10.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar11.jpg) | [⌊Answer15mar2022⌉](https://isnr.in/wp-content/uploads/2022/03/15mar12.jpg) |

LEGENDS:

•Axial CT image (a, b) shows hyperdense structures with calcification in the right
ambient cistern, bone reformats (c, d) shows hypoplasia and malformed right carotid
canal. Calcifications were seen in the shrunken right globe. •Axial T2 weighted 
images (e, f) shows multilobulated T2 hypointense structures in the right ambient
cistern with absence of right ICA flow void.  There is right phthisis bulbi. ASL
image (g) shows spin trapping in these structures. Post contrast T1 MPRAGE (h) shows
lobulated enhancing vessels •DSA image (i, j) reveals ectatic dilated right P1 with
multilobulated aneurysmal appearance. There is reformation of the right ACA and 
MCA from the contralateral circulation through the ACOM. Right PCOM is not visualized(
image k). There is occlusion of right ICA (image l)

# Dolichoectasia of right PCA with right ICA occlusion

•Dolichoectasia of the PCA is rarity and is usually postulated to be developmental/
acquired at birth, in contrast to the commoner vertebro-basilar dolichoectasia which
is essentially atherosclerotic ^(1)

•Relating to the embryological basis of segmental ICA genesis, this selective vulnerability
of the ICA and PCA can be explained by the fact that PCOM and PCA are derived from
the caudal ramus of the ICA and are then transferred to the posterior circulation
^(2,3) .

•Patients can present with non-specific specific symptoms like headache, cranial
nerve compression, subarachnoid hemorrhage, transient ischemic attacks or infarcts
and management varies accordingly- medical management to surgery/ intervention

•Imaging- CT, CTA, MRI and MRA plays a crucial role in diagnosis and DSA being able
to demonstrate the vascular nature of the lesion and facilitate appropriate management.

•Learning point: Affliction of ICA and PCA in this case can be explained by segmental
vulnerability due to vascular insult/ infection in the perinatal / in utero period
causing mutilation of the endothelium, leading to ICA occlusion and dolichoectasia
of PCA.

## References:

1. Pico F, Labreuche J, Amarenco P. Pathophysiology, presentation, prognosis, and
management of intracranial arterial dolichoectasia. Lancet Neurol. 2015 Aug;14(8):
833–45.

2. Lasjaunias PL. Segmental Identity and Vulnerability in Cerebral Arteries. Interv
Neuroradiol. 2000 Jun;6(2):113–24. 

3. Kobkitsuksakul C, Somboonnitiphol K, Apirakkan M, Lueangapapong P, Chanthanaphak
E. Dolichoectasia of the internal carotid artery terminus, posterior communicating
artery, and posterior cerebral artery: The embryonic caudal ramus internal carotid
segmental vulnerability legacy. Interv Neuroradiol. 2020 Apr;26(2):124–30.