Posterior Inferior Cerebellar Artery Stroke Due to a Severe Right Vertebral Artery Stenosis With a Left Cervical Internal Carotid Artery Dissection: What's Next?

Abstract

Guidelines for the treatment and management of ischemic strokes triggered by stenosis versus dissection are well established. However, the presence of both entities in the same patient, although rare, poses challenges for short- and long-term treatment. Here, we describe the case of a 55-year-old man who presented to the emergency department with a 72-hour history of headache, dizziness, unbalanced gait, nausea, and two episodes of vomiting. Stroke was initially suspected, but the computerized tomography (CT) scan showed no hemorrhage. His magnetic resonance imaging (MRI) showed right inferior cerebellar acute ischemia in the territory of the right posterior inferior cerebellar artery (PICA), with smaller foci of early acute infarcts in the bilateral inferior cerebellum. Furthermore, magnetic resonance angiography (MRA) and CT angiography revealed right vertebral artery stenosis and left cervical internal carotid artery dissection (ICAD). This clinical report describes a rare case of stroke secondary to vertebral artery stenosis with concomitant carotid artery dissection. The treatment course and evolution are presented.

Keywords: acute ischemic stroke (ais); carotid artery dissection; prevention of ischemic stroke; stroke management; vertebral artery stenosis.

Figure 1. Infarction of right cerebellar hemisphere

Brain magnetic resonance imaging (A: T2-Flair and B: T2-Diffusion Weighted Imaging) showing a hyperintense lesion (arrow) in the right inferior cerebellar hemisphere representing an acute confluent infarction with a small hemorrhagic conversion from right posterior inferior cerebellar artery (PICA) territory stroke. Additional smaller foci of early acute versus subacute infarcts in the bilateral inferior cerebellum are noted.

Figure 2. Left cervical internal carotid artery (ICA) dissection

Brain contrast magnetic resonance angiography showing a linear filling defect, creating a double lumen (yellow arrow) visible in the left cervical internal carotid artery (ICA), a finding of ICA dissection versus thrombus. The remaining portions of the left internal carotid artery and the right internal carotid arteries are patent without evidence of significant stenosis or occlusion.

Figure 3. Right vertebral artery stenosis

CT angiogram (CTA) of head and neck with contrast showing the circumferential noncalcified plaque of the V1 segment proximal right vertebral artery causing severe, greater than 90% stenosis. The left vertebral artery is patent. The vertebral arteries are symmetric in size, both contribute to the basilar artery.