Series of cases presented at the weekly neurovascular conference.

1. Neurovascular Conference
Farrukh Chaudhry, MD. Neurovascular Fellow
Daniel Vela-Duarte, MD. PGY-2

2. Patient 2
Sudden onset emesis and vertigo

3. History of Present Illness
• 74 y/o right handed AA man with:
• Sudden onset emesis at 10 am
• By 1 am, the emesis started again accompanied by severe vertigo and
headache
• Taken to an outside ED where he was found to have:
• Right hemiparesis
• Head CT unremarkable
• Transfer to Loyola for further care
• 6 hours after the onset of symptoms
• No IV thrombolysis at outside institution
• Prior history of stroke in early 30's, BPH and HTN
• His son died from large stroke in his 30's as well

4. Neurological exam
• Corneal anesthesia on the right
– Decreased right corneal response
• Impaired abduction of the right eye
• Mild horizontal/rotary nystagmus on far right lateral gaze
• Lower motor neuron facial paresis on the right
• Deafness right ear
• Right sided hemiataxia
• Right sided truncal lateropulsion
• Hypalgesia and thermoanesthesia of the right face (onion skin
pattern) and left hemibody

5. Localization

6. Diffusion-weighted images.

7. MRA Carotids MRA
A1 segment of the R ACA (Congenital hypoplasia)
R Vert is dominant
L vert originates from aortic arch

8. MRA Vertebrals
MRA
R Vert is dominant
L vert originates from aortic arch

9. Ancillary Data
• Echocardiogram:
– LV Ejection Fraction: 60 %
– Mild LV hypertrophy
– Mild LA enlargement
• Lipid panel : Chol: 166 | Trigl: 52 | HDL: 47 | LDL: 111
• HgbA1c: 5.6
• BMP normal | CBC: mild anemia
• EKG with NSR
• Telemetry monitoring without any events

10. Day # 2. F/ Up CT

14. Cerebellum blood supply.
The PICA arises from the vertebral Art. and courses transversely and
downward along the medulla. The common trunk gives rise to the
medial branch (medPICA) and the lateral branch (latPICA).

15. Distribution of blood supply.

16. Cerebellar Strokes
• PICA 40%
• SCA 36%
• AICA 12%
• Multiple vascular territories 12%

17. Clinical Presentation of PICA infarcts
• Structures affected
– Inferior surface of cerebellar hemisphere/inferior cerebellar peduncle
– Spinothalamic tract
– Descending sympathetic pathway
– Descending tract of Vth nerve
– Vestibular nuclei
– Nucleus ambiguous
• Clinical presentation
• Ipsilateral • Contralateral
• Horner’s syndrome • Hemibody hypesthesia &
• Facial hypesthesia & thermoanesthesia
thermoanesthesia • Vertigo
• Hemiataxia • Hoarseness
• Palatal asymmetry • Dysphagia

18. Clinical Presentation of AICA infarcts
• Structures affected
– Brachium pontis
– Spinothalamic tract
– Descending sympathetic pathway
– VII nerve intra-axial fascicular portion
– Descending tract of Vth nerve
– Vestibular nuclei
– Cochlear nucleus
• Clinical presentation
• Ipsilateral • Contralateral
• Horner’s syndrome • Hemibody hypesthesia &
• Facial weakness thermoanesthesia
• Facial hypesthesia & • Vertigo
thermoanesthesia • Nystagmus
• Hemiataxia
• Deafness

19. Discussion

20. Why presence of Bell’s phenomena
and Dysartrhia
• Because the medial branch of PICA participates in
the blood supply of the medulla in its rostral
region
• Up to 30% of the PICA distribution infarctions
also involve the lateral medulla, resulting in
ipsilateral Horner Syndrome / decreased
sensation in the ipsilateral trigeminal distribution
• Dysarthria: Speech Ataxia