However, a T2 weighted 3D curved MPR image revealed the luminal dilation and intimal flap in the right proximal PICA (Fig. Moreover, the sagittal 3D T1 weighted HR vw-MRI showed a T1 hyperintense intramural hematoma in the right proximal PICA (Fig. The right PICA was not observed in the first CTA, and partial spontaneous recanalization was observed on the time-of-flight MR angiography (TOF-MRA), which was taken one day after. HR vw-MRI was taken a day after (at the 4th-day). CT angiography (CTA) was taken first at 3 days after the symptom occurred. The diagnosis was determined to be an acute ischemic stroke because the diffusion weighted imaging (DWI) of MRI revealed a high signal intensity area in the right lateral medulla. The results of serological studies and electrocardiography were normal. The results of a neurological examination showed lateropulsion to the right side, hypoesthesia on the right side of the face, ataxia in the right upper and lower limbs, and the NIH stroke scale was 2. When the patient visited the emergency room, his blood pressure was 160/100 mmHg, the pulse rate was 62/min, breathing rate was 19/min, and body temperature was 36.5 ☌. He also did not have a history of taking antiplatelet agents. The patient did not have any underlying diseases, history of migraines, or risk factors for stroke, except for smoking. There was no history of an external injury within the past one week. This study presents two cases in which an intimal flap was detected on the curved multiplanar reconstruction image reconstructed from three-dimensional (3D) HR vw-MRI (3D curved MPR image).Ī 56-year-old male patient came to the emergency room due to a right-sided occipital headache and vertigo, which suddenly began three days before the visit, and a symptom of tilting to the right, which began one day before the visit. Therefore, it may be important to visualize a direct sign such as an intimal flap or double lumen. Although an intramural hematoma is a pathognomonic sign of PICA dissection, it may be necessary to distinguish it from intraplaque hemorrhage. Recent studies have diagnosed isolated PICA dissection in patients by using high-resolution vessel wall MRI (HR vw-MRI), in which a T1 hyperintense intramural hematoma was the main finding. However, it is still difficult to accurately diagnose PICA dissection because the size of the PICA is very small. Owing to the recent development of imaging technology, more studies have reported isolated PICA dissection. However, it is important to diagnose PICA dissection accurately and as early as possible because it can cause ischemic stroke or subarachnoid hemorrhage. The incidence of spontaneous isolated posterior inferior cerebellar artery (PICA) dissection is very rare. Furthermore, we believe that 3D curved MPR imaging could improve the possibility of diagnosing the dissection early because it can easily confirm direct signs such as an intimal flap or double lumen. HR vw-MRI is useful for the early diagnosis of isolated PICA dissection. Therefore, these two patients were diagnosed with spontaneous isolated PICA dissection due to the intimal flap that was observed on the 3D curved MPR image. However, 3D curved MPR imaging discovered the intimal flap which was not observed on the routine HR vw-MRI. In this report, routine HR vw-MRI revealed only an intramural hematoma in both patients. The curved multiplanar reconstruction image reconstructed using three-dimensional (3D) HR vw-MRI (3D curved MPR imaging) is helpful to observe tortuous blood vessels such as the PICA because it can visualize the entire vessel course in a single plane. Two patients with posterior circulation ischemic stroke due to spontaneous isolated PICA dissection underwent HR vw-MRI. The intimal flap or double lumen, which is commonly reported to be a direct sign of the dissection, is not easily detectable on HR vw-MRI because the size of the PICA is very small and tortuous. Spontaneous isolated posterior inferior cerebellar artery (PICA) dissection has been reported more frequently since high-resolution vessel wall magnetic resonance imaging (HR vw-MRI) was introduced to the field.
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