Posterior circulation infarct

Case contributed by Derek Smith
Diagnosis certain

Presentation

Found unconscious at home. Well the night before. GCS 6 on arrival in emergency department.

Patient Data

Age: 55 years
Gender: Male

Initally reported as normal examination.

On review of original non-contrast scan by neuro-radiologists hypodensities and loss of deep grey matter in thalamic areas noted.

Angiogram/venogram studies

ct

Diffuse posterior circulation hypoperfusion compared with ACA/MCA systems.

No evidence of AVM, dissection or occlusive pathology. No venous thrombosis.

2 day interval to MRI

mri

Extensive posterior circulation infarct with signal abnormality and restricted diffusion in: both medial thalami, midbrain, both dentate gyri, both occipital lobes, left cerebellar hemisphere. Small caliber posterior circulation vessels, but no absent signal voids.

The patient remained obtunded and was managed in the intensive care unit under sedation and ventilation. He required feeding support as his swallow, conscious level and motor effort in general were impacted but slowly recovered.

There was a long rehabilitation period following this posterior circulation stroke. The patient remained broadly cognitively impaired with fluctuant levels of alertness. He relied on assistance to mobilize with a frame and was left with severe visual impairment and limited downgaze.

Follow up study (eight months)

ct

Chronic infarcts in midbrain, bilateral medial thalami and right occiptal lobe.

No acute findings.

Case Discussion

This young patient suffered a debilitating posterior circulation stroke.  The long term effects of infarcting important structures in the brainstem and basal ganglia illustrate the importance of these structures and are important review areas in head imaging.

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