Avoiding pitfalls in diagnosing basilar artery occlusive disease
clinical and imaging clues — case report
Keywords:
Stroke, Carotid artery diseases, Basilar artery, Hemiparesis, Brain stem infarctionsAbstract
CONTEXT: The aim of this paper was to report on the characteristics that aid in establishing the diagnosis of basilar artery occlusive disease (BAOD) among patients with hemiparesis and few or minor symptoms of vertebrobasilar disease. CASE REPORT: This report describes two cases in a public university hospital in São Paulo, Brazil. We present clinical and imaging findings from two patients with hemiparesis and severe BAOD, but without clinically relevant carotid artery disease (CAD). One patient presented transient ischemic attacks consisting of spells of right hemiparesis that became progressively more frequent, up to twice a week. The neurological examination revealed slight right hemiparesis and right homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed pontine and occipital infarcts. Magnetic resonance angiography and digital subtraction angiography revealed severe basilar artery stenosis. The other patient presented sudden left-side hemiparesis and hypoesthesia. One year earlier, she had reported sudden onset of vertigo that, at that time, was attributed to peripheral vestibulopathy and was not further investigated. MRI showed a right-side pontine infarct and an old infarct in the right cerebellar hemisphere. Basilar artery occlusion was diagnosed. Both patients presented their symptoms while receiving aspirin, and became asymptomatic after treatment with warfarin. CONCLUSIONS: Misdiagnosing asymptomatic CAD as the cause of symptoms in BAOD can have disastrous consequences, such as unnecessary carotid endarterectomy and exposure to this surgical risk while failing to offer the best available treatment for BAOD. Clinical and imaging features provided important clues for diagnosis in the cases presented.
Downloads
References
Mohr JP, Caplan LR, Melski JW, et al. The Harvard Cooperative Stroke Registry: a prospective registry. Neurology. 1978;28(8):754-62.
Nighoghossian N, Ryvlin P, Trouillas P, Laharotte JC, Froment JC. Pontine versus capsular pure motor hemiparesis. Neurology. 1993;43(11):2197-201.
Vemmos KN, Spengos K, Tsivgoulis G, et al. Aetiopathogenesis and long-term outcome of isolated pontine infarcts. J Neurol. 2005;252(2):212-7.
Kasner SE, Lynn MJ, Chimowitz MI, et al. Warfarin vs aspirin for symptomatic intracranial stenosis: subgroup analyses from WASID. Neurology. 2006;67(7):1275-8.
Koroshetz WJ. Warfarin, aspirin, and intracranial vascular disease. N Engl J Med. 2005;352(13):1368-70.
Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ische- mic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006;37(2):577-617.
Eberhardt O, Naegele T, Raygrotzki S, Weller M, Ernemann U. Stenting of vertebrobasilar arteries in symptomatic atherosclerotic disease and acute occlusion: case series and review of the literature. J Vasc Surg. 2006;43(6):1145-54.
Imai K, Mori T, Izumoto H, et al. Transluminal angioplasty and stenting for intracranial verte- brobasilar occlusive lesions in acute stroke patients. AJNR Am J Neuroradiol. 2008;29(4): 773-80.
Nahab F, Lynn MJ, Kasner SE, et al. Risk factors associated with major cerebrovascular complications after intracranial stenting. Neurology. 2009;72(23):2014-9.
Kaps M, Klostermann W, Wessel K, Brückmann H. Basilar branch disease presenting with progressive pure motor stroke. Acta Neurol Scand. 1997;96(5):324-7.
Feldmann F, Wilterdink JL, Kosinski A, et al. The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) trial. Neurology. 2007;68(24):2099-106.
