Abstract
Secondary stroke prevention requires early initiation of antiplatelet; therefore,
stroke mimics need to be ruled out particularly in circumstances when antiplatelet
therapy can be of disastrous consequences. A 54-year-old female patient presented
to the emergency department with symptoms of sudden-onset deviation of angle of mouth
to the right side, left eye ptosis, and occipital headache for past 4-hour duration.
Neurologic examination revealed right-sided gaze-dependent torsional nystagmus and
left lower motor neuron facial weakness. An embolic posterior circulation stroke secondary
to vertebral artery dissection was suspected. Diffusion-weighted imaging (DWI) did
not show any acute infarcts, and careful review of susceptibility-weighted imaging
(SWI) scans showed hemorrhage in the fourth ventricle. Subsequent digital subtraction
angiography (DSA) was done, which showed left anterior inferior cerebellar artery
(AICA) aneurysm involving its intrameatal segment with AICA-posterior inferior cerebellar
artery (PICA) complex. Retrospective review of computed tomographic (CT) angiography
images showed small aneurysm in the internal auditory meatus, which is difficult to
discern secondary to adjacent bony structure and smaller size of the aneurysm. The
patient underwent endovascular coiling of the aneurysm with preservation of the parent
artery. Our experience concluded that these clinical features suggest remote subarachnoid
hemorrhage secondary to the ruptured of AICA intrameatal segment aneurysm with left
facial nerve paralysis and peripheral cochlear vestibular changes secondary to either
compression (mechanical or pulsations of the aneurysm sac) or ischemia of vestibular
apparatus. The neurointerventionist should consider the possibility of aneurysmal
rupture, especially in cases of atypical location of hemorrhage and no signs of infarct
on neuroimaging of posterior circulation stroke.
Keywords
meatal AICA aneurysm - AICA-PICA complex - endovascular coiling
