A case of multiple Vertebrobasilar artery fenestration misdiagnosed as vertebral artery dissection

Fenestration of vertebra-basilar artery is an uncommon congenital vascular anomaly, which is identified by incidental findings on imaging in patients presented without related symptoms or in patients with intracerebral hemorrhage secondary to concomitant artery aneurysm or arteriovenous malformations. Yet, cases of fenestration being misdiagnosed as cerebral artery dissection have never been reported.

We present a patient of 66-year-old female with acute onset of dizziness after chiropractic manipulation of the neck. Neck computed tomography angiography (CTA) showed 'double lumen' sign and 'intimal flap' of the V1 segment of the vertebral artery, which led to the initial diagnosis of vertebral artery dissection (VAD). However, vertebral artery fenestration at V1 segment was eventually identified by multi-directional digital subtraction angiography (DSA). Interestingly, concomitant vertebral fenestration at V3 segment, basilar fenestration and basilar artery tip aneurysm was also revealed by DSA.

The triple fenestration at vertebrobasilar artery with basilar tip artery aneurysm is extremely rare, and the fenestration at the V1 segment of vertebral artery was easily misdiagnosed as VAD due to the similar imaging morphology.