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Neurovascular ConferenceFarrukh Chaudhry, MD. Neurovascular FellowDaniel Vela-Duarte, MD. PGY-2
Patient 2Sudden onset emesis and vertigo
History of Present Illness• 74 y/o right handed AA man with:   • Sudden onset emesis at 10 am   • By 1 am, the emesis star...
Neurological exam• Corneal anesthesia on the right   – Decreased right corneal response• Impaired abduction of the right e...
Localization
Diffusion-weighted images.
MRA Carotids   MRA               A1 segment of the R ACA (Congenital hypoplasia)               R Vert is dominant         ...
MRA Vertebrals                 MRA                 R Vert is dominant                 L vert originates from aortic arch
Ancillary Data•   Echocardiogram:     – LV Ejection Fraction: 60 %     – Mild LV hypertrophy     – Mild LA enlargement•   ...
Day # 2. F/ Up CT
Cerebellum blood supply.The PICA arises from the vertebral Art. and courses transversely anddownward along the medulla. Th...
Distribution of blood supply.
Cerebellar Strokes•   PICA 40%•   SCA 36%•   AICA 12%•   Multiple vascular territories 12%
Clinical Presentation of PICA infarcts• Structures affected   –   Inferior surface of cerebellar hemisphere/inferior cereb...
Clinical Presentation of AICA infarcts• Structures affected   –   Brachium pontis   –   Spinothalamic tract   –   Descendi...
Discussion
Why presence of Bell’s phenomena            and Dysartrhia• Because the medial branch of PICA participates in  the blood s...
Right AICA PICA stroke
Right AICA PICA stroke
Right AICA PICA stroke
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Right AICA PICA stroke

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Series of cases presented at the weekly neurovascular conference.

Right AICA PICA stroke

  1. 1. Neurovascular ConferenceFarrukh Chaudhry, MD. Neurovascular FellowDaniel Vela-Duarte, MD. PGY-2
  2. 2. Patient 2Sudden onset emesis and vertigo
  3. 3. 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
  4. 4. 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
  5. 5. Localization
  6. 6. Diffusion-weighted images.
  7. 7. MRA Carotids MRA A1 segment of the R ACA (Congenital hypoplasia) R Vert is dominant L vert originates from aortic arch
  8. 8. MRA Vertebrals MRA R Vert is dominant L vert originates from aortic arch
  9. 9. Ancillary Data• Echocardiogram: – LV Ejection Fraction: 60 % – Mild LV hypertrophy – Mild LA enlargement• Lipid panel : Chol: 166 | Trigl: 52 | HDL: 47 | LDL: 111• HgbA1c: 5.6• BMP normal | CBC: mild anemia• EKG with NSR• Telemetry monitoring without any events
  10. 10. Day # 2. F/ Up CT
  11. 11. 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).
  12. 12. Distribution of blood supply.
  13. 13. Cerebellar Strokes• PICA 40%• SCA 36%• AICA 12%• Multiple vascular territories 12%
  14. 14. Clinical Presentation of PICA infarcts• Structures affected – Inferior surface of cerebellar hemisphere/inferior cerebellar peduncle – Spinothalamic tract – Descending sympathetic pathway – Descending tract of Vth nerve – Vestibular nuclei – Nucleus ambiguous• Clinical presentation• Ipsilateral • Contralateral • Horner’s syndrome • Hemibody hypesthesia & • Facial hypesthesia & thermoanesthesia thermoanesthesia • Vertigo • Hemiataxia • Hoarseness • Palatal asymmetry • Dysphagia
  15. 15. Clinical Presentation of AICA infarcts• Structures affected – Brachium pontis – Spinothalamic tract – Descending sympathetic pathway – VII nerve intra-axial fascicular portion – Descending tract of Vth nerve – Vestibular nuclei – Cochlear nucleus• Clinical presentation• Ipsilateral • Contralateral • Horner’s syndrome • Hemibody hypesthesia & • Facial weakness thermoanesthesia • Facial hypesthesia & • Vertigo thermoanesthesia • Nystagmus • Hemiataxia • Deafness
  16. 16. Discussion
  17. 17. 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

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