Rapunzel syndrome is caused by gastric trichobezoar with extended tail and small bowel obstruction. Patients with gastric trichobezoar can be asymptomatic until the bezoar increases in size. We report a case of a girl who visited the emergency department with abdominal pain. She was finally diagnosed with Rapunzel syndrome that causes multiple small bowel intussusceptions associated with trichophagia. Surgery was needed to reduce the multiple intussusceptions, and to remove the large trichobezoar. This case highlights to consider the possibility of Rapunzel syndrome when diagnosing the main cause of intussusceptions.
Abdominal Pain ; Bezoars ; Emergency Service, Hospital ; Female ; Humans ; Intestinal Obstruction ; Intussusception ; Pica ; Tail ; Trichotillomania

Vertebral artery injuries associated with C1 lateral mass screw insertion rarely occur during C1-2 fusion. The posterior inferior cerebellar artery (PICA) is uncommonly located at the C1 lateral mass insertion position. A 71-year-old woman with atlanto-axial subluxation and cord compression underwent C1-2 fusion. Sixth nerve palsy and diplopia were detected postoperatively, and decreased consciousness occurred on postoperative day 4. Brain magnetic resonance image (MRI) and computed tomography (CT) revealed PICA infarction. In the preoperative CT angiography, the PICA originated between the C1 and C2 level. In the postoperative CT scan, the PICA was not visible. The patient was treated conservatively for two weeks and recovered. PICA originating between the C1 and C2 level comprises 1.1–1.3% of cases. Therefore, vertebral artery anomalies should be evaluated prior to C1-2 fusion to prevent vessel injuries.
Abducens Nerve Diseases ; Aged ; Angiography ; Arteries ; Brain ; Brain Infarction ; Consciousness ; Diplopia ; Female ; Humans ; Infarction ; Pica ; Tomography, X-Ray Computed ; Vertebral Artery

We describe the case of a patient who had infarction of the posterior inferior cerebellar artery (PICA) after a chiropractic cervical manipulation. A 39-year-old man visited the emergency room with signs of cerebellar dysfunction, presenting with a 6-hour history of vertigo and imbalance. Two weeks ago, he was treated by a chiropractor for intermittent neck pain. At the time of admission, brain computed tomography, magnetic resonance imaging, and angiography revealed an acute infarction in the left PICA territory and occlusion of the extracranial vertebral artery (VA; V1/2 junction) as a result of the dissection of the VA. Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. He was treated with antiplatelet therapy. Three weeks later, he was discharged without any sequelae. The possibility of VA dissection should be considered at least once in patients presenting with cerebellar dysfunctions with a recent history of chiropractic cervical manipulation.
Adult ; Angiography ; Arteries* ; Brain ; Cerebellar Diseases ; Cerebral Infarction ; Chiropractic* ; Emergency Service, Hospital ; Humans ; Infarction* ; Lateral Medullary Syndrome ; Magnetic Resonance Imaging ; Manipulation, Chiropractic* ; Manipulation, Spinal ; Neck Pain ; Pica ; Vertebral Artery ; Vertigo

A 64-year-old female presented with an incidentally-discovered right posterior inferior cerebral artery (PICA) aneurysm, initially treated in 2015 by simple coiling. Follow-up demonstrated significant coil compaction that required retreatment. Retreatment was done uneventfully using a Pipeline embolization device (PED) shield deployed starting from the basilar artery and ending at the V4 segment of the vertebral artery. Eight-weeks post-deployment, a follow-up digital subtraction imaging (DSA) and intravascular imaging with optical coherence tomography were obtained. The intravascular imaging demonstrated that the flow diverter had good wall apposition and concentric neointimal growth over the braid with exception to the areas that the PED was not in contact with the endothelial wall, such as at the right PICA ostium and at the vertebrobasilar junction. The entire procedure was safe, and the patient had no complications. In this article, we describe for the first time the assessment of the status of endothelial “healing” of the PED shield at 8-weeks.
Aneurysm ; Basilar Artery ; Cerebral Arteries ; Female ; Follow-Up Studies ; Humans* ; Middle Aged ; Pica ; Retreatment ; Tomography, Optical Coherence* ; Vertebral Artery

OBJECTIVE: Sometimes a vertebral artery (VA) enters the spinal canal via the C1–2 intervertebral space, a variation regarded as a C2 segmental-type VA. This paper describes the anatomy of the C2 segmental-type VA and reviews its clinical importance.METHODS: Between March 2014 and November 2015, 3386 patients underwent computed tomographic angiography. I identified C2 segmental-type VAs, associated vascular variation, the origin of ipsilateral posterior inferior cerebellar arteries (PICAs), and the clinical symptoms associated with C2 segmental-type VAs. The origin of an ipsilateral PICA is divided into 5 types. A type 1 PICA originates from ipsilateral VAs coursing suboccipitally (IVASO), a type 2 originates from ipsilateral proximal C2 segmental-type VAs, a type 3 originates from ipsilateral distal C2 segmental-type VAs. For type 4, the PICA does not originate from an ipsilateral VA. For type 5, the PICA is the terminal end of an ipsilateral C2 segmental-type VA.RESULTS: One hundred thirteen patients had 121 C2 segmental-type VAs; 47 were associated with an IVASO, and 74 were not. Four type 1, 13 type 2, 60 type 3, 42 type 4, and two type 5 PICAs were identified. Only one patient showed symptoms associated with a C2 segmental-type VA, being a 71-year-old man presenting with a C2 segmental-type VA infarction.CONCLUSION: For C2 segmental-type VAs, the ipsilateral IVASO and origin of the PICA are important for predicting the outcome of this type of VA infarction.
Aged ; Angiography ; Arteries ; Congenital Abnormalities ; Humans ; Infarction ; Pica ; Spinal Canal ; Vertebral Artery

OBJECTIVE: Surgical obliteration of ruptured aneurysm of the proximal posterior inferior cerebellar artery (PICA) is challenging because of limited surgical accessibility. In recent years, coil embolization is the first-choice treatment for these lesions. However, coil embolization is not always easy in ruptured PICA aneurysm owing to the variable anatomical diversity of its shapes, its relationship to the parent artery, its low incidence, and accordingly, lesser neurointerventionist experience.METHODS: The parent artery and microcatheter for easier navigation and the embolization technique for stable coiling were identified.RESULTS: This study aimed to identify the more appropriate approach route, microcatheter, and strategies for an easier and safer, and more durable coil embolization in the treatment of lesions in the proximal PICA.CONCLUSION: Coil embolization for aneurysmal subarachnoid hemorrhage due to a ruptured proximal PICA remains a challenge, but with the appropriate coiling plan, it can be treated successfully.
Aneurysm ; Aneurysm, Ruptured ; Arteries ; Embolization, Therapeutic ; Humans ; Incidence ; Parents ; Pica ; Subarachnoid Hemorrhage

The safety and feasibility of simple coil embolization and stent deployment for the treatment of posterior inferior cerebellar artery (PICA) aneurysms, as well as their radiologic and clinical results, have not been adequately understood. Especially, if dissecting aneurysm of proximal PICA is associated with small caliber PICA and stenosis of ipsilateral vertebral artery orifice (VAO), endovascular coiling with saving of PICA is not always easy. This 64-year-old man presented with subarachnoid hemorrhage due to a ruptured dissecting aneurysm of left proximal PICA. The aneurysm was irregularly fusiform in nature with a shallow PICA orifice (1.4 mm) and narrow caliber (0.9–1.5 mm). Moreover, the ipsilateral VAO showed severe stenosis (1.8 mm). We performed bifemoral puncture and chose additional route from right vertebral artery to left vertebrobasilar junction for retrograde approach and deployment of LVIS Jr. intraluminal support at proximal PICA. And then, the antegrade approach and coiling of aneurysm was done. Despite of transient thrombus of PICA, the aneurysm was successfully secured with preservation of whole PICA course. For preservation of narrow PICA with ipsilateral VAO stenosis, the contralateral approach and deployment of LVIS Jr. intraluminal support may be considered.
Aneurysm ; Aneurysm, Dissecting ; Arteries ; Constriction, Pathologic ; Embolization, Therapeutic ; Humans ; Middle Aged ; Pica ; Punctures ; Stents ; Subarachnoid Hemorrhage ; Thrombosis ; Vertebral Artery

BACKGROUND: Patient-controlled epidural analgesia (PCEA) is known to provide good postoperative analgesia in many types of surgery including laparoscopic surgery. However, no study has compared PCEA with patient-controlled intravascular analgesia (PCIA) in laparoscopic radical prostatectomy (LARP). In this study, the efficacy and side effects of PCEA and PCIA after LARP were compared. METHODS: Forty patients undergoing LARP were randomly divided into two groups: 1) a PCEA group, treated with 0.2% ropivacaine 3 ml and 0.1 mg morphine in the bolus; and 2) a PCIA group, treated with oxycodone 1 mg and nefopam 1 mg in the bolus. After the operation, a blinded observer assessed estimated blood loss (EBL), added a dose of rocuronium, performed transfusion, and added analgesics. The numeric rating scale (NRS), infused PCA dose, and side effects were assessed at 1, 6, 24, and 48 h. RESULTS: EBL, added rocuronium, and added analgesics in the PCEA group were less than those in the PCIA group. There were no significant differences in side-effects after the operation between the two groups. Patients were more satisfied with PCEA than with PCIA. The NRS and accumulated PCA count were lower in PCEA group. CONCLUSIONS: Combined thoracic epidural anesthesia could induce less blood loss during operations. PCEA showed better postoperative analgesia and greater patient satisfaction than PCIA. Thus, PCEA may be a more useful analgesic method than PICA after LARP.
Administration, Intravenous ; Analgesia ; Analgesia, Epidural ; Analgesia, Patient-Controlled ; Analgesics ; Anesthesia, Epidural ; Humans ; Injections, Epidural ; Laparoscopes ; Laparoscopy ; Methods ; Morphine ; Nefopam ; Oxycodone ; Pain Measurement ; Pain, Postoperative ; Passive Cutaneous Anaphylaxis ; Patient Satisfaction ; Pica ; Prostatectomy ; Thoracic Vertebrae

Ischemic stroke caused by spontaneous thrombosis of posterior inferior cerebellar artery (PICA) aneurysm has been rarely reported. A 52-year-old man presented with sudden headache, dizziness, and gait disturbance. Diffusion-weighted MRI showed acute infarction in left PICA territory. A saccular aneurysm with internal thrombus at the distal PICA was detected by CT angiography and conventional angiography. The thrombus resolved spontaneously at 2 months after stroke onset with aspirin medication. At that time, endovascular coiling was underwent successfully to prevent aneurysmal rupture.
Aneurysm* ; Angiography ; Arteries* ; Aspirin ; Cerebral Infarction ; Dizziness ; Gait ; Headache ; Humans ; Infarction* ; Magnetic Resonance Imaging ; Middle Aged ; Pica ; Rupture ; Stroke ; Thrombosis*

Arterial dissection is an important cause of stroke. We report two cases of isolated posterior inferior cerebellar artery (PICA) dissection diagnosed by high-resolution vessel-wall MRI (HRVW-MRI). One subject complained of abrupt-onset vertigo and headache, and the other subject had headache, vertigo, and Horner syndrome. Conventional MRA showed only focal dilatation of the PICA, but HRVW-MRI revealed intramural hematoma and double-lumen contour in the PICA, suggesting arterial dissection. We suggest that the use of HRVW-MRI should be considered when diagnosing isolated PICA dissection in a PICA infarct with an unknown cause.
Arteries* ; Dilatation ; Headache ; Hematoma ; Horner Syndrome ; Magnetic Resonance Imaging* ; Pica ; Stroke ; Vertigo