Transient total locked-in syndrome due to vertebral and basilar artery dissection

Abstract

A 52-year-old woman suddenly presented with right conjugate eye deviation, anarthria and quadriplegia, and appeared to be in a deep coma. MRI revealed a new infarct in the left cerebellar hemisphere and stenosis in the distal portion of the basilar artery caused by arterial dissection. Her deficits improved within 6 hours of onset. Moreover, on day 1, she described that she had been alert and her vision, hearing and somatic sensation had been preserved during the illness. Total locked-in syndrome should be considered while assessing patients with total immobility who are unable to communicate.

Keywords: brain stem / cerebellum; stroke.

Figure 1

(A–D) MRI at 100 min after onset. (A) Diffusion-weighted image revealing a fresh infarct in the upper region of the left cerebellar hemisphere. (B) Basiparallel anatomic scanning revealing the normal outer appearance of the basilar artery. (C) MR angiography revealing segmental narrowing in the distal portion of the basilar artery. (D) T2-weighted image revealing a high-intensity area on the ventral wall in the distal portion of the basilar artery, where the narrowing lesion was observed on MR angiography. (E, F) MRI at 30 hours after onset. (E) MR angiography revealing partial resolution of the segmental narrowing of the basilar artery. (F) T1-weighted image revealing a high-intensity area on the ventral wall in the distal portion of the basilar artery. (G, H) MRI on day 13. (G) MR angiography revealing narrowing and a new object indicating a haematoma (arrowhead) in the dissecting lumen in the distal portion of the left vertebral artery as well as narrowing of the basilar artery. (H) T1-weighted image revealing a hyperintense lesion in the left vertebral artery where the narrowing lesion was observed on MR angiography. (I, J) MRI on day 103. (I) MR angiography revealing partial remission of the stenosis in the left vertebral artery. (J) T1-weighted image indicating the disappearance of the hyperintense lesion in the left vertebral artery.