Diagnosis: Cerebral aneurysm, nonrupturedClinical question: view for hemorrhageSigns and Symptoms: s/p large vertebral aneurysm s/p embolization and clipping MRI of the brainNo diffusion weighted abnormalities are appreciated.There is a 42x33x36mm sagittal dimension premedullary and prepontine mass (thrombosed aneurysm with coils distally and proximally) with heterogenous signal on T1 and T2 associated with flow voids. Much of the signal is hyperintense on T1WI.The brainstem is displaced and compressed posteriorly by the mass and drapes over the mass. The inferior aspect of the 4th ventricle is narrowed and the foramina of Luschka are distorted. There is mixed signal along the periphery of the mass on SWI phase imaging with some bright signal and some dark signal some of which is opposite in signal on the corresponding magnitude SWI images (suggesting peripheral calcification). The vertebral arteries and basilar artery are contiguous with this mass.A similar signal characteristic well-circumscribe mass is present in the left upper carotid space measuring 16x22xmm. It is stable compared to the prior exam.The temporal horns of the lateral ventricles are dilated. Overall there is mild enlargement of the third ventricle (10 mm width) and lateral ventricles (41mm biventricular diameter at the level of foramina of Monro).There are several supratentorial periventricular and subcortical white matter T2 and FLAIR hyperintense lesions without diffusion restriction.Normal vascular flow voids are present in the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal right vertebral artery, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.The patient is status post embolic coil occlusion of a 44x35x35mm giant vertebrobasilar aneurysm and occlusion of the LVA intracranially. Stents are present in the RVA across the origin of the aneurysm. There is a residual 2mm aneurysm at the more proximal RVA neck of the aneurysm extending superiorly. There is a 26x26x16 mm LICA cervical segment aneurysm redemonstrated which has a different opacification pattern on the current exam relative to the prior exam.The anterior communicating artery is identified. The posterior communicating arteries are identified. There is extracranial origin of the right PICA. The LVA is diminutive distally. The left PICA is not readily identified.
1.Status post stent assisted embolic coil occlusion of a vertebrobasilar junction giant aneurysm and embolic occlusion of the left vertebral artery (LVA) distal to the PICA. There is 2mm residual filling of the aneurysm at the neck of the RVA component of the aneurysm. The left PICA is not readily identified which may be a result of the field strength of the magnet. If there are referable clinical symptoms a CTA or conventional angiography may be useful.2.The overall dimensions of the aneurysm and the mass effect remain stable compared to the prior exam. The ventricles are stable.3.Stable size of LICA cervical segment dissecting aneurysm. Difference in filling pattern may be due to difference in field strength of the magnet. At some point a CTA or conventional angiography may be useful to further assess this.4.No evidence for acute ischemic cerebral infarction.