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 30s, BPH and HTN• His son died from large stroke in his 30s as well
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
Cerebellum blood supply.The PICA arises from the vertebral Art. and courses transversely anddownward along the medulla. The common trunk gives rise to themedial branch (medPICA) and the lateral branch (latPICA).
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