• Hidenori Hoda, Hirokazu Takami, Christopher S Graffeo, Kazuo Hanakawa, Masaki Komiyama, Masahiko Murao, and Takafumi Ide.
• Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan; Trauma and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan. Electronic address: hoda-tmhp@umin.ac.jp.
• World Neurosurg. 2020 Feb 1; 134: 641-646.e4.

BackgroundTraumatic vertebral artery dissection (tVAD) is frequently accompanied by cerebellar infarction, but subarachnoid hemorrhage (SAH) is rare.Case DescriptionWe report a unique case of tVAD precipitating SAH, from which the patient fully recovered, most likely because of the protective effects of an anomalously duplicated posterior inferior cerebellar artery (PICA) origin. A 17-year-old Sumo wrestler experienced a brief loss of consciousness after an attack by an opponent to his neck. Head computed tomography imaging demonstrated diffuse posterior fossa SAH; cerebral angiography demonstrated left vertebral artery (VA) occlusion, which was thought to be most likely attributable to tVAD. Angiography revealed distal PICA reconstitution, supplied by collateral arterial flow from the meningeal branch of the proximal ipsilateral VA. An external ventricular drain was placed acutely for treatment of SAH-induced hydrocephalus; however, the patient had an otherwise uneventful course, and remained without clinical evidence of ischemic infarct. A repeat imaging confirming a probable duplicated PICA origin from the VA, distal to the tVAD-associated thrombosis.ConclusionsOf particular interest, the patient's abnormal anatomy may have been a mixed blessing, with a more fragile bifid PICA potentially underlying the unexpected development of SAH, whereas the sister branch simultaneously spared him a potentially catastrophic infarction via arterial collateralization.Copyright © 2019 Elsevier Inc. All rights reserved.

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