Sumo-associated traumatic vertebral artery dissection precipitating subarachnoid hemorrhage in association with bifid origins of the posterior inferior cerebellar artery

Abstract Traumatic vertebral artery dissection (tVAD) is frequently accompanied by cerebellar infarction, but subarachnoid hemorrhage (SAH) is rare. We report a unique case of tVAD precipitating SAH, from which the patient fully recovered, most likely due to 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 following an attack by an opponent to his neck. Head computed tomography imaging demonstrated diffuse posterior fossa SAH; cerebral angiography demonstrated left VA occlusion, thought most likely attributable to tVAD. Angiography revealed distal PICA reconstitution, supplied by collateral arterial flow from the meningeal branch of the proximal ipsilateral vertebral artery. 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. Of particular interest, our patient’s abnormal anatomy may have been a mixed blessing, with potentially a more fragile bifid PICA potentially underlying the unexpected development of SAH, while the sister branch simultaneously spared him a potentially catastrophic infarction via arterial collateralization.