Balloon angioplasty for acute posterior communicating artery occlusion due to dissection: illustrative case

BACKGROUND: Acute occlusion of the posterior communicating artery (PComA) due to dissection is rare, and the optimal revascularization strategy has not been established. The authors report a case of acute PComA occlusion due to suspected arterial dissection in a patient with a fetal-type posterior cerebral artery (PCA), successfully treated with balloon angioplasty. OBSERVATIONS: A 66-year-old woman presented with acute-onset impaired consciousness and left hemiparesis. CT angiography revealed right PComA occlusion associated with a fetal-type PCA. Cerebral angiography performed after intravenous thrombolysis demonstrated transient recanalization of the PComA with severe residual stenosis, followed by reocclusion. Because the lesion appeared stenotic rather than embolic, balloon angioplasty was performed, resulting in favorable antegrade PCA flow restoration. During follow-up, an intimal flap, gradual improvement in stenosis, and vessel wall hyperintensity on volumetric isotropic turbo spin-echo acquisition imaging were observed, suggesting spontaneous PComA dissection as the underlying etiology. The modified Rankin Scale score was 2 at 90 days after symptom onset. LESSONS: Balloon angioplasty may be a feasible revascularization strategy for acute PComA occlusion when arterial dissection is suspected. https://thejns.org/doi/10.3171/CASE26592.