Bilateral PICA Territory Infarcts of Right Lateral Medulla and Left Cerebellum via Spontaneous Common PICA Dissection

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The posterior inferior cerebellar artery (PICA) supplies not only the caudal part of the cerebellar hemisphere and vermis, but also the dorsolateral portion of the medulla oblongata.1 Right and left PICAs typically originate from the right and left distal vertebral arteries, respectively.Bilateral cerebellar infarcts in PICA territories have been previously reported and the common PICA (c-PICA) on one side was proposed as a possible mechanism to explain bilateral PICA territory infarcts.[2][3][4] Although autopsy-proven cases have supported this idea, 5 there have been rare well-described case reports confirming the idea of c-PICA on one side and the underlying etiology using digital subtraction angiography (DSA) and high-resolution magnetic resonance imaging (MRI).Here, we report a case of bilateral PICA territory infarcts involving right lateral medulla and left cerebellum via c-PICA dissection. CASE REPORTA 57-year-old female patient visited the emergency room (ER) due to acute sustained vertigo which started about 20 hours before she arrived ER during travel in Shanghai.She also complained of gait imbalance and nausea.Neurological examination revealed right ptosis, right upper and lower limb ataxia and gaze-evoked nystagmus, suggestive of Wallenberg's syndrome.Diffusion-weighted MRI confirmed right lateral medullary infarct and left cerebellar infarct in bilateral PICA Bilateral cerebellar infarcts in posterior inferior cerebellar artery (PICA) territories have been previously reported and the common PICA (c-PICA) on one side was proposed as a possible mechanism.We report a case of bilateral PICA territory infarcts involving right lateral medulla and left cerebellum via spontaneous c-PI-CA dissection.Digital subtraction angiography (DSA) revealed that bilateral PICAs originated from the c-PICA arising from the right vertebral artery with luminal irregularity.Eccentric enhancement of the c-PICA on 3D multi-planar reformatted images suggested arterial dissection or atherosclerosis rather than vasculitis.Susceptibility-weighted image showed a blooming effect around the c-PICA and the phase map revealed eccentric high signal intensity on the vessel wall of the c-PICA, implicating intramural thrombus in c-PICA dissection.We investigated the mechanism and etiology of bilateral PICA territory infarcts using DSA and high-resolution magnetic resonance imaging (MRI) and elucidated the dissection of the c-PICA.

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