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Posterior circulation aneurysm is very uncommon (20%) and vertebral artery (VA) are even rarer with only 0.3-3% of all intracranial aneurysms with limited known natural history. They can be extracranial or intracranial in location from the foramen magnum, vertebral-posterior inferior cerebellar artery junction to the vertebral-basilar junction.3,4 Due to the diffi cult location and its rare presentation they are a challenge to most neurosurgeons. They can be saccular, dissecting or atherosclerotic fusiform type.2 They classically present with sudden onset headache, nausea, vomiting, gait disturbance, seizure, loss of consciousness, features of stroke or embolism and vertigo. Features of meningism, isolated neck pain and features of backache can also be present.1,4 A 56-year old male presented with sudden severe vertigo without tinnitus, headache, diffi culty in walking and disorientation to time and person for seven days. There was no history of fever, trauma, vomiting, seizure or any signifi cant other medical history. He was initially managed with ear nose throat surgeon with no relief of symptoms. On examination he was conscious but disorientated. There was no cranial nerve, motor or sensory defi cit. His hematological and biochemical profi le was in normal range. Computed Tomogram (CT) was done which showed a large 4X4 cm well-defi ned calcifi ed mass with internal hypodensity in the left cerebellar hemisphere without edema. An initial diagnosis of metastases or glioma was suspected and a Magnetic Resonance Imaging advised (MRI). MRI showed a left cerebellar 4X3.7X3 cm relatively well-defi ned lobulated lesion with concentric signals, central T1 hyperintensity, hypointense T2/FLAIR signal without any enhancement on contrast. There was mild perilesional edema and was indenting the adjacent cerebellum, pons, displacing the medulla and IVth ventricle to the opposite side. The features were suggestive of a thrombosed left vertebral aneurysm. CT angiography was then done which showed non fi lling of the left intracranial vertebral aneurysm just distal to the foramen magnum and Giant Thrombosed “Divine Clipped” Vertebral Artery Aneurysm Presenting with Severe Vertigo Dr Yam Bahadur Roka MS, M.Ch., IFAANS

Giant Thrombosed "Divine Clipped" Vertebral Artery Aneurysm Presenting with Severe Vertigo