Presentation
Sudden onset blurry vision, nausea/vomiting, and gait unsteadiness.
Patient Data
On the diffusion-weighted series, moderate to large sized acute infarcts involve the bilateral cerebellar hemispheres. Smaller acute infarcts involve the cerebellar vermis. An acute right PCA distribution infarct involves the right temporal occipital lobes medially, also involving the right thalamocapsular junction. A punctate acute lacunar infarct involves the right posterior medulla.
No associated hemorrhagic transformation is present. Mild edema and swelling from the cerebellar infarcts causes mild partial effacement of the fourth ventricle. There is no associated hydrocephalus at this time. close serial imaging follow-up over time is recommended to monitor for stability.
Multiple acute posterior circulation infarcts involve the bilateral cerebellum (moderate to large in size), and right temporal occipital PCA distribution, without hemorrhagic transformation.
In the neck, marked decreased flow is noted involving the proximal and mid cervical segments of the right vertebral artery consistent with a high-grade stenosis, dissection, or thrombus. The distal cervical segment of the right vertebral artery and the intracranial segment of the right vertebral artery are patent which could reflect collateral flow, slow anterograde flow, or retrograde flow across the vertebral basilar junction. Follow-up axial T1 fat saturation series of the neck and contrast enhanced neck MRA are recommended for further evaluation.
Case Discussion
This case highlights the interplay between vascular abnormalities and cerebral infarction. A point of interest is the right vertebral artery, which was found to display signs suggestive of collateral flow, slow anterograde flow, or retrograde flow across the vertebrobasilar junction. These findings are typically seen in response to some degree of stenosis or occlusion within the vessel.
The altered hemodynamics may be related to the patient's neurological presentation. The patient suffered multiple acute posterior circulation infarcts, notably in the bilateral cerebellum (moderate to large in size) and right temporal occipital lobes, areas supplied by the posterior cerebral artery (PCA) distribution. The MRA supports the notion that the right vertebral artery, with its aberrant flow characteristics, is likely the embolic source, leading to thromboembolic events within the posterior ciruclation.
The presence of an embolic source would explain the widespread and bilateral nature of the infarcts, as emboli could potentially dislodge and travel to various distal sites, causing infarctions in multiple territories.
Co-author: Habib Zahir, DO.
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