A case of bilateral cerebellar infarction in the distribution of the bilateral superior cerebellar artery]

We reported a case of bilateral cerebellar hemorrhagic infarction in the distribution of the bilateral superior cerebellar artery. A 58-year-old man suddenly developed dizziness and transient loss of consciousness. The neurological examination revealed left hearing disturbance, left sensory disturbance involving face, dysarthria and bilateral ataxia. This patient was considered to be classic clinical syndrome of right superior cerebellar artery. CT and MRI revealed hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery. The right posterior cerebral artery was filling through the right posterior communicating artery on the right carotid angiography taken 2 hours after the onset. Bilateral vertebral angiography on the 18th day demonstrated no occlusions in the basilar artery and the bilateral superior cerebellar artery. Hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery, sparing other territories as the present case, is extremely rare. In this case, cerebral embolism (top of the basilar syndrome) was suggested because of existence of atrial fibrillation and sudden onset.     

Bilateral vertebral artery dissection and its chronological changes detected by MR angiography: a case report]

A case of intracranial bilateral vertebral artery (VA) dissection presenting with ischemic symptoms which following unilateral dissection is presented. A 42-year-old male with an occipital headache was pointed out right vertebral artery stenosis with magnetic resonance (MR) angiography 8 day before admission. He admitted to our hospital complaining of severe vertigo and tinnitus. MR images and cerebral angiograms revealed bilateral VA dissection with infarcts in light lower surface of cerebellum perfused by posterior inferior cerebellar artery and right hypothalamus. Conservative therapy was adopted and serial MR angiography was performed. His symptoms were improved gradually and MR angiograms obtained 2 months later revealed improvement of bilateral VA stenosis. It is generally accepted that VA dissection presenting ischemic symptoms has good outcome by conservative therapy only. However, its pathological process of progression is still unknown. Based on the serial MR findings, we discuss the mechanisms of bilateral VA dissection. In this case, we consider that unilateral VA dissection extended to contralateral vertebral artery through the vertebrobasilar junction. Frequent MR angiography in acute phase could be of great use for monitoring the progression of dissection.     

Vertebral artery dissection and migraine headaches in children

Strokes of the posterior circulation are uncommon in childhood. In vertebrobasilar insults, vertebral artery dissection remains a rare diagnosis. We report the case of an 8-year-old boy with a history of migraine headaches who presented with acute cerebellar signs and agitation following multiple infarctions of bilateral cerebellar hemispheres. Vertebral angiography demonstrated dissection of the left vertebral artery with occlusion of the basilar artery just distal to its origin. Risk factors for vertebral artery dissection are reviewed, with emphasis on association with migraine headaches. A review of imaging studies for the diagnosis of dissection is also presented. This case demonstrates the importance of considering arterial wall dissection in pediatric patients with a history of atypical migraines associated with new neurologic findings.     

Bilateral deafness as a prodromal symptom of basilar artery occlusion.

Bilateral deafness is a rare but possible symptom for ischemia of the vertebrobasilar system, primarily derived from occlusion of anterior inferior cerebellar arteries or their branches. Patients 1 and 2 developed sudden bilateral deafness, soon followed by coma. The proximal segment of the basilar artery was occluded due to atherothrombosis in Patient 1 and arterial dissection in Patient 2. Thrombolytic therapy failed to recanalize the basilar arterial flow. Both patients died of extensive infarction in the vertebrobasilar arterial territory. Sudden bilateral deafness can be a warning sign of imminent brainstem ischemia by occlusion of the basilar artery regardless of age. Prompt and intensive management for stroke is needed for patients with sudden bilateral deafness.     

Dissection of the Extracranial Vertebral Artery: Clinical Findings and Early Noninvasive Diagnosis in 24 Patients

Dissection of cervical arteries causes ischemic stroke in young adults. This reports the clinical, ultrasonographic, and neuroradiological findings in 24 patients with 28 vertebral artery dissections in the neck (4 occurring bilaterally). In 20 patients (83%), the dissection was temporally related to trauma. No patients had an underlying vascular disease, for example, atherosclerosis or fibromuscular dysplasia. In all, the major initial manifestation was pain in the occipital or neck region. The next most common symptoms were vertigo and nausea (in 17 patients). Clinical manifestations were vertebrobasilar transient ischemic attack (TIA) (5 patients: in 2 patients vestibulocerebellar TIA, in 1 patient visual TIA, in 1 patient motor TIA, and in 1 patient brain stem TIA with perioral paresthesia), cerebellar infarction (10 patients, in 4 patients bilateral), brainstem infarction (5 patients), posterior cerebral artery territory infarction (1 patient), and multiple vertebrobasilar ischemic lesions (3 patients). Typical angiographic findings were irregular narrowing of the vessel lumen or a tapering stenosis with distal occlusion. Magnetic resonance imaging showed a thickened vessel wall with hematoma signal at the site of the dissection. Duplex color-flow imaging was valuable for the early diagnosis of extracranial vertebral artery dissection and for follow-up examinations. The distal V1- and the proximal V2-segment (at the level of C6 vertebra) was the most frequent localization of dissections (in 43%). The outcome was favorable except for 2 patients with basilar artery occlusion. Embolism to the basilar artery may be avoided by early administration of anticoagulants.     

A case report of bilateral cerebral peduncular infarction manifesting tetraparesis and pseudobalbur palsy]

A 63-year-old female had presented with right hemiparesis and slight dysarthria. MRI had showed the infarction of left pons and left peduncle. Three months later she further presented with left hemiparesis, severe dysarthria and swallowing disturbance. MRI showed bilateral cerebral peduncular infarction. And the angiogram showed the occlusion of basilar artery at the just distal portion of the superior cerebellar artery. We recognized our case as the infarction due to the basilar artery occlusion. The 16 cases of bilateral cerebral peduncular infarction were reported. In these reports, the symptoms of bilateral cerebral peduncular infarction were locked-in syndrome in 15 cases and persistent vegetative state in only one case. Our patient presented with tetraparesis and pseudobalbur palsy not with locked-in syndrome, probably because the area of infarction was limited within almost lateral portion of peduncle. The sparing of posterior cerebral artery was one of the reason of such a condition. This is the first report of bilateral cerebral peduncular infarction manifesting tetraparesis and pseudobalbur palsy.     

A young adult case of spontaneous basilar artery dissection]

We reported a case of basilar artery dissection in a 20-year-old man suffering sudden onset of consciousness disturbance. Brain CT revealed a cerebral infarction of the whole territories of vertebro-basilar artery and his 3DCT showed the occlusion at the base of basilar artery. Autopsy revealed that the subintimal dissection was found at the base of basilar artery and the dissection was spreaded to the distal of bilateral posterior cerebral arteries. The characteristics of his vertebro-basilar artery were small in diameter, thin media and thickened intima. According to these findings, we supposed this rare case of basilar dissection occurred all at once based on a functional abnormality in his small vertebro-basilar arterial wall.     

Bilateral sudden deafness as a prodrome of anterior inferior cerebellar artery infarction

BACKGROUND: Acute ischemic stroke in the distribution of the anterior inferior cerebellar artery is known to be associated with hearing loss, facial weakness, ataxia, nystagmus, and hypalgesia. There have been few reports on bilateral deafness and vertebrobasilar occlusive disease. Furthermore, previous reports have not emphasized the inner ear as a localization of bilateral deafness. OBJECTIVE: To describe the presentation of acute ischemic stroke in the distribution of the anterior inferior cerebellar artery as sudden bilateral hearing loss with minimal associated signs. DESIGN AND SETTING: Case report and tertiary care hospital. PATIENT: A 66-year-old man with diabetes mellitus developed sudden bilateral deafness, unilateral tinnitus, and vertigo 7 days before the onset of dysarthria, facial weakness, and ataxia. T2-weighted magnetic resonance imaging scans showed hyperintensities in the right lateral pons and right middle cerebral peduncle and a possible abnormality of the left middle cerebellar peduncle. A magnetic resonance angiogram showed moderately severe stenosis of the distal vertebral artery and middle third of the basilar artery. The patient's right limb coordination and gait improved steadily over several weeks, but there was no improvement in hearing in his right ear. CONCLUSIONS: The relatively isolated onset of deafness as well as the severity and persistence of the hearing loss led us to conclude that the hearing loss in this case was likely due to prominent hypoperfusion of the internal auditory artery, with labyrinthine infarction as the earliest event. Vertebrobasilar occlusive disease should be considered in the differential diagnosis of sudden bilateral deafness.     

Bilateral paramedian midbrain infarct: an uncommon variant of the "top of the basilar" syndrome

Occlusion of the rostral portion of the basilar artery can result in ischaemia of the midbrain and thalami, as well as of the temporal and occipital lobes. The so called "top of the basilar" syndrome manifests clinically as numerous combinations of abnormalities of alertness, sleep-wake cycle, and behaviour and oculomotor or pupillomotor functions. A 67 year old man presented with bilateral internuclear ophthalmoplegia, rubral tremor, and daytime somnolence. He was awake during the night and mostly agitated and aggressive. An ischaemic lesion was visible on the magnetic resonance (MR) image in the central portion of the midbrain just ventral to the aqueduct, clearly affecting the paramedian structures bilaterally. MR angiographic images demonstrated a hypoplastic basilar artery ending in both superior cerebellar arteries. Both posterior cerebral arteries were seen to arise from the corresponding internal carotid arteries via the posterior communicating branches. This unique case of an acute bilateral paramedian infarct represents a highly uncommon variant of the "top of the basilar" syndrome and was due to the affected ischaemic territory--that is, the "distal field" of the variant basilar artery.     

Obliteration of bilateral dissecting aneurysms of the vertebral arteries following repeated subarachnoid hemorrhage: a case report

A 51-year-old man presented with loss of consciousness when he underwent urological examination at another hospital. CT scans showed subarachnoid hemorrhage, and cerebral angiography showed bilateral dissecting aneurysms of the vertebral arteries. Following ventricular drainage, the lesion was managed conservatively with blood pressure control but again ruptured on day 8. Cerebral angiography revealed narrowing of both the dissecting aneurysms. On day 11, the right vertebral artery had been spontaneously obliterated and the right dissecting aneurysm was filled in a retrograde fashion via the left vertebral artery. Proximal occlusion of the right vertebral artery was performed to prevent recanalization. Two months later, cerebral angiography revealed that both vertebral arteries were obliterated and the basilar artery and right posterior inferior cerebellar artery were filled via the right posterior communicating artery. The present case demonstrated that the hemodynamic status of bilateral dissecting aneurysms of the vertebral artery changed variably indicating the necessity of careful angiographic observation.     

Obliteration of bilateral dissecting aneurysms of the vertebral arteries following repeated subarachnoid hemorrhage: A case report

Abstract

A 51-year-old man presented with loss of consciousness when he underwent urological examination at another hospital. CT scans showed subarachnoid hemorrhage, and cerebral angiography showed bilateral dissecting aneurysms of the vertebral arteries. Following ventricular drainage, the lesion was managed conservatively with blood pressure control but again ruptured on day 8. Cerebral angiography revealed narrowing of both the dissecting aneurysms. On day 11, the right vertebral artery had been spontaneously obliterated and the right dissecting aneurysm was filled in a retrograde fashion via the left vertebral artery. Proximal occlusion of the right vertebral artery was performed to prevent recanalization. Two months later, cerebral angiography revealed that both vertebral arteries were obliterated and the basilar artery and right posterior inferior cerebellar artery were filled via the right posterior communicating artery. The present case demonstrated that the hemodynamic status of bilateral dissecting aneurysms of the vertebral artery changed variably indicating the necessity of careful angiographic observation.     

A case of ischemic disturbance of inner ear

We reported a 51-year-old male with ischemic disturbance of right inner ear resembling Meniere's disease. The patient had a sudden-onset episode of vertigo, right severe hearing disturbance, nausea, vomiting and gait disturbance. Two days after, he had hypersomnia, vertical gaze palsy, double vision, left Horner's sign, and sensory disturbance of pain and temperature of right half body involving face. Brain MRI disclosed high intensity area in T2-weighted image and proton density in bilateral paramedian thalamo-mesencephalic region and right cerebellum (area of the anterior inferior cerebellar artery). Cerebral angiography showed 90% or more stenosis of the right vertebral artery, 50% stenosis of the left vertebral artery before the posterior inferior cerebellar artery (PICA), and 60% stenosis of distal portion of the basilar artery. Furthermore, stem portion of the posterior cerebral artery, and the right anterior cerebellar artery and the left vertebral artery after the PICA were absent or occluded. Right deafness was evaluated to be Jerger type II, namely disturbance of inner ear. Caloric tests showed no response, and right auditory brainstem response showed no waves. Main cause of this vertigo and right deafness was considered to be disturbance of inner ear due to ischemia of right labyrinthine artery, though this patient was not a typical case of the anterior cerebellar artery syndrome. Ischemic disturbances of inner ear have been reported only in patients with the anterior cerebellar artery syndrome, therefore this patient who had only acute ischemic disturbance of inner ear and did not have disturbance of caudo-lateral portion of the pons was considered to be very rare.     

Stroke in patients with fusiform vertebrobasilar aneurysms

We studied seven patients with brainstem infarction and large fusiform vertebrobasilar (VB) aneurysms to clarify the clinical, radiologic, and pathologic features. All presented with pontine infarcts; one also had a cerebellar infarct. VB TIAs preceded brainstem infarction in four patients. Angiography and CT documented VB fusiform aneurysmal dilatation. Four had intraluminal thrombi and one had severe basilar artery stenosis. Two distinct clinical pictures emerged: unilateral pontine infarcts with favorable outcome, presumably related to obstruction of a pontine penetrating artery at its origin from the posterior wall of the aneurysmal basilar artery, and major fatal bilateral pontine infarcts from basilar artery occlusion. Two patients came to autopsy. One had thrombus in the dilated basilar artery and a posterior cerebral artery branch embolus with hemorrhagic occipital infarction; the other had basilar artery thrombus with aneurysmal rupture and subarachnoid hemorrhage. Fusiform VB aneurysms caused brainstem stroke by intraluminal thrombus, local embolism, atherostenosis, and obstruction of paramedian penetrating arteries. Subarachnoid hemorrhage is an uncommon complication.     

A case of brain stem infarction with bilateral hearing impairment and tinnitus at the onset

We reported a 49-year-old male with brain stem infarction who had bilateral hearing impairment and tinnitus at the onset and subsequently developed various neurological symptoms, including bilateral lateral inferior pontine syndrome, one and a half syndrome and upward gaze palsy. Although CT scan failed to reveal any abnormalities initially, MRI revealed symmetrical foci bilaterally from the lateral inferior pons to the middle cerebellar peduncle, as well as in the paramedian portion of the mid-pons. Cerebral angiography: The left vertebral artery (VA) occluded at the 4th segment. The right VA showed severe stenosis at the 4th segment. The basilar artery (BA) was found to be occluded in the lower 1/3 below the clivus. Furthermore, CAG demonstrated upper portion of the BA, bilateral superior cerebellar artery and posterior cerebral artery via the posterior communicating artery, but the bilateral anterior inferior cerebellar arteries (AICAs) were absent or occluded. Neuroradiological findings suggested ischemia in the bilateral AICA and the middle portion of the BA. Bilateral hearing impairment rarely accompanies cerebrovascular disorders. This case of bilateral hearing impairment, tinnitus at the onset, followed by bilateral lateral inferior pontine syndrome was considered to be an extremely rare pathological condition.     

Atypical Megadolichoectasia Manifesting as Brain Infarction Rapidly Followed by Fatal Subarachnoid Hemorrhage

A 71‐year‐old female, without medical or family history for cerebrovascular disease, presented with basilar and bilateral carotid dolichoectasia manifesting as dysarthria and hemisensory disturbance, which resolved spontaneously within a day. She suffered brainstem infarction 28 months later, manifesting as drowsiness, dysarthria, and right hemiparesis. Her consciousness level progressively deteriorated to stupor within 4 days. Computed tomography taken on the 5th day confirmed cerebellar infarct in the perfusion area of the superior cerebellar artery but did not show subarachnoid hemorrhage. She died of acute respiratory failure on the 7th day. Autopsy demonstrated a tear in the lateral wall of the broad‐based aneurysm on the ectatic basilar artery and diffuse subarachnoid hemorrhage. Vertebrobasilar ectasia is a dynamic vasculopathy that may rapidly progress in the affected basilar artery following an indolent clinical course. The prognosis for patients with vertebrobasilar ectasia may depend mainly on the pathological changes in the basilar artery.     

Persistent primitive first cervical intersegmental artery (proatlantal artery II) with occlusion of the basilar artery--a case report

A rare case of persistent primitive first cervical intersegmental artery (proatlantal artery II) is reported. A 58-year-old man was admitted to our hospital with dysarthria and left hemiparesis. On admission he was stuporous with bilateral gaze palsy and left hemiparesis. CT scan on admission showed low density areas in the right cerebellar hemisphere and ventricular part of the pons. Right retrograde brachiography revealed occlusion of the basilar artery, aplasia of the right vertebral artery and an abnormal vessel connecting the right external carotid artery and the right vertebral artery. This anastomotic vessel was thought to be a persistent primitive first cervical intersegmental artery (Proatlantal artery II). Left carotid angiography revealed the left posterior cerebral artery was visualized through the posterior communicating artery, leading from the internal carotid artery. Left retrograde brachial angiography showed that the left vertebral artery terminated just distal from the branching of the left posterior inferior cerebellar artery. After admission the left hemiparesis deteriorated gradually and tracheotomy was done due to respiratory difficulties. The patient was then transferred to the rehabilitation center on his 34th day in hospital with neurological deficits.     

lnterleukin-2 and Cisplatinum Therapy Toxicity Mimicking Basilar Artery Disease

A 51-year-old woman receiving cis-platinum and interleukin-2 for metastatic melanoma developed a clinical picture suggesting basilar artery occlusion. Magnetic resonance imaging and computed tomography showed bilateral occipital lucencies.     

Fibromuscular dysplasia of the basilar artery presenting as cerebral infarction in a young female]

We reported a 20-year-old woman with fibromuscular dysplasia (FMD) of the basilar artery presenting multiple cerebral infarctions. A sudden onset of consciousness disturbance and right hemiparesis was experienced. A neurological examination on day 2 revealed an absence of light and corneal reflexes on the left side, homonymous left upper quadrant anopsia and right hemiparesis with Babinski sign: she was also somnolent. On head MRI, multiple high signal intensity lesions were seen in the right occipital lobe, bilateral thalami and left pons on T2- and diffusion weighted images. Brain angiogram revealed the string of beads sign of the basilar artery, suggesting FMD. Neurological deficits gradually improved in the 2 months that followed, leaving slight hemiparesis and homonymous left upper quadrant anopsia In the following 3 years, no recurrence was seen with aspirin (81 mg/day). FMD in the head and neck usually affects extracranial segments of the carotid and vertebral arteries, while FMD of the basilar artery is extremely rare. To the best of our knowledge, 12 cases with FMD of the basilar artery have been reported; of these, 11 were symptomatic and 5 died. Since FMD of the basilar artery has poor prognosis, attention needs to be paid for FMD in young adults as a differential diagnosis of cerebral infarction in the territory of the basilar artery.     

Juvenile-onset multiple brain infarcts localized in the posterior circulation: a case report]

We report a 37-year-old male patient with multiple brain infarcts due to arterial lesions localized in the posterior circulation, who developed a paramedian pontine infarct on the left side. He had been treated as schizophrenia for 20 years. A cranial CT performed one year before showed old small infarcts in the territories of the bilateral thalamo-perforating and left thalamo-geniculate arteries and the right posterior inferior cerebellar artery. The vertebral and basilar arteries were small in diameter on MRI and MR angiography(MRA). Cerebral angiography revealed a narrow smooth basilar artery. In addition, the P2 segments of the bilateral posterior cerebral arteries were markedly narrow with irregular walls. Carotid arteriograms were normal and no atherosclerosis was found. The nature of these arterial lesions remains unknown in this case. Even if MRA shows vertebrobasilar artery hypoplasia, a known congenital risk factor of a posterior circulation infarct, we must rule out a possibility that some arterial pathology is going on.     

Neuropsychological and behavioural impairments resulting from bilateral thalamic infarct

The neuropsychological characteristics of a patient with a bilateral thalamic infarct in the posterior communicating artery territory due to basilar artery thrombosis are described. MRI examination showed bilateral thalamic acute ischemic lesions in the zone anterior to the tuberothalamic branches. In the cognitive exploration, the patient showed verbal and visual memory disorders, impairment of the executive functions including inability to generate and make decisions and behavioural disorders including lack of inhibition, euphoria, and occasional aggressiveness. Two months later the patient had improved in the neuropsychological test scores but still suffered from severe recent memory loss, and certain behavioural disorders including lack of inhibition and euphoria. Other cases on thalamic infarcts with cognitive and behavioural impairments due to disconnection of the front subcortical pathways have been described in the literature.