Acute pontine infarction

Case contributed by Mohd Radhwan Bin Abidin
Diagnosis certain

Presentation

Background diabetes mellitus, hypertension, and dyslipidemia. Presented with sudden onset of limb weakness and speech slurring. On examination, positive cerebellar signs with power right limb 4/5.

Patient Data

Age: 50 years
Gender: Female

Plain CT Brain

ct

Fairly ill-defined hypodensity at right frontal region. No acute intracranial hemorrhage. 

Diagnosis: Likely recent infarction. 

*Note: no abnormal lesion at cerebellar/pontine region.

MRI Brain

mri

There are a few areas of hypointense signal on T1, hyperintense on T2, and FLAIR, with restricted diffusion on DWI at central pons and the left side of the pons. 

Few areas of T2 and FLAIR hyperintensities at the posterior limb of the left internal capsule, anterior limb of the right internal capsule, right corona radiata, both occipital regions, and right midbrain. No restricted diffusion on DWI at this region. 

MRA shows the presence of segmental narrowing of the right ICA, with the longest involving the distal petrous and lacerum segment. Another short segment narrowing is seen involving the clinoid and ophthalmic segment. The right M1 segment also appears relatively smaller compared to that of the left side. 

Diagnosis:

1.    Acute infarctions at pons.

2.    Multifocal old infarctions.

3.    Multiple segmental narrowings of the right internal carotid artery.

Case Discussion

The diagnosis for this case is acute pons infarction. This is confirmed by restricted diffusion on DWI. 

Few other lesions show chronic infarctions. The MRA shows segmental narrowing of the right ICA, however, no abnormal signal on the basilar artery (which supplies the pons). 

Other differentials of pontine lesions are demyelination, pontine neoplasm (such as astrocytoma), and metastasis. 

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