Cerebellar infarct due to vertebral artery dissection with posterior fossa decompression
Presentation
Neck pain and unsteadiness.
Patient Data
Non-contrast study is largely normal although, with the benefit of the perfusion findings, it is possible to vaguely make out hypodensity in the PICA territory on the right. A hyperdense "dot" is present posterior to the medulla and in the inferior 4th ventricle that suggests a hyperdense artery sign.
Perfusion maps demonstrate an area of reduced CBF and CBV and elevated MTT and TTP conforming to the right PICA territory.
CT angiography confirms non-opacification for the right PICA. The right vertebral artery is irregular as it passes through the dura consistent with a dissection.
24 hours post symptom onset
The infarct is now well circumscribed and swelling has begun with effacement of the basal cisterns surrounding the pontomesencephalic junction. A smaller contralateral cerebellar infarct has also developed. This is presumably due contralateral supply by the PICA.
36 hours post symptom onset
A posterior fossa suboccipital decompressive craniectomy has been performed with duroplasty allowing the infarcted brain to herniate posteriorly and reducing mass effect on the brain stem.
Continued expected evolution of the infarct with progressive extracranial herniation.
Day 10
Continued evolution with significant reduction in mass effect and increased downward extracranial herniation.
Case Discussion
A decompressive craniectomy can be life saving when posterior fossa infarcts are sizable and swelling is severe.
Unable to process the form. Check for errors and try again.