Vascular pattern and radiological follow up in a case of pontine warning syndrome

Abstract

Pontine warning syndrome (PWS) is a condition characterized by crescendo transient ischemic attacks due to pontine ischemia. The reported case described a 72-year-old woman who presented repetitive sudden episodes of double vision, impaired balance, slurred speech and right-sided weakness. Neurological deficits lasted a few minutes-hours and disappeared during the first seven days after onset. On the 1st day, MRI revealed acute left paramedian pontine infarction with focal swelling. Supra-aortic vessel imagining revealed bilateral internal carotid stenosis of 50%; hypoplasia of the left vertebral artery. On the 7th day, MRI showed a tissue swelling reduction, and from that day, she had no symptoms. These clinical and radiological features were suggestive of PWS. Our patient presented a particular vascular pattern that could favour symptoms fluctuation. We performed a close MRI follow up and it allowed us to observe a clinical stabilization in association with edema reduction.

Keywords: Acute pontine ischemia; Carotid stenosis; MRI follow up; Pontine warning syndrome; Vertebral artery hypoplasia.

Figure 1

Pontine ischemic lesion on Magnetic Resonance Imaging. DWI: Diffusion Weighted Imaging; FLAIR: Fluid Attenuation Inversion Recovery.

Figure 2

Supra-aortic vascular pattern on Computed Tomography Angiography (CTA). (A) Right internal carotid artery stenosis; (B) Left internal carotid artery stenosis; (C) Left vertebral artery hypoplasia; (D) Vertebral arteries 3d reconstruction.