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Isolated posterior cerebral artery dissecting aneurysm presenting as an unconventional intracerebral hemorrhage

To the Editor, Arterial dissection mostly involves the vertebral and basilar arteries with intracranial carotid, middle cerebral (MCA), and posterior cerebral artery (PCA) dissection occur rarely.1 Herein, we describe a case of a spontaneous isolated PCA dissecting aneurysm with unusual intracerebral hemorrhage (ICH). A 41yearold previously healthy female presented with sudden severe headache, confusion, and right hemiparesis. She is a nonsmoker with no prior history of trauma or vigorous physical activity. On presentation, her blood pressure was 154/93 mmHg. She had poor pupillary light response with vertical gaze palsy. Noncontrasted computed tomography of the brain (Figure 1) showed intraventricular hemorrhage (IVH) and ICH extending from pons to the left lentiform nucleus. Angiographic neuroimaging showed a saccular aneurysm of the left PCA abutting the midbrain with aneurysm dome pointing toward the cortex. Digital subtraction angiography confirmed P1P2 dissecting aneurysm as evident by irregular dilatation and contour of the vessel wall with proximal stenotic segment at the origin of P1. The angiogram did not demonstrate any significant abnormality in the perforator arteries. She subsequently underwent successful endovascular coiling as part of the acute treatment. Her echocardiography, hematological, and connective tissue disease screening were normal. The patient showed gradual recovery and was planned for intracranial stenting of the left PCA after the acute phase of her bleed. Isolated PCA aneurysms are commonly present in younger females at the P2P3 junction near the tentorium cerebelli. Dissection can affect the medialadventitial region of the arteries, causing subarachnoid hemorrhage (SAH).1 This report aims to highlight the unusual pattern of isolated ICH and/or IVH without SAH from a dissected PCA aneurysm.2