This paper is a case report of a 22 year old young, previously healthy woman that presented comatose to the Emergency Room at Landspitali University Hospital Iceland. A CT image of the head on admission revealed a large infarct of the right cerebellar infarct with oedema that was compressing the fourth ventricle. A CT angiogram on admission was suspicious for a dissection of the left vertebral artery (confirmed during endovascular treatment) and a total occlusion of the distal third of the basilar artery which was confirmed during endovascular treatment. Thrombolytic therapy with t-PA was initiated followed by thrombectomy with good recanalization. The following day the patient underwent suboccipital craniotomy for malignant cerebellar infarction. She made a good clinical recovery to a modified Raning scale of 1 at 90 days after discharge from the hospital. Following the case is aA literature review on the clinical aspects of occlusion of the vVertebrobasilar system, use and utility of imaging and studies, treatment with (anticoagulation, IV and IA thrombolysis) modalities that have been tried. Finally, the evidence regarding and thrombectomy and as well as a discussion of the role of craniotomy for malignant stroke are reviewed.

1Dep. of Neurology Landspitali University Hospital Iceland, 2Dep. of Radiology Sahlgrenska University Hospital, Gothenburg, Sweden, 3Dep. of Interventional Radiology University, Hospital Iceland, 4Dep. of Neurosurgery University Hospital Iceland, 5Dep. of Rehabilitation Landspitali University Hospital Iceland

 

Key words: Vertebrobasilar occlusion, angiogram, anticoagulation, information from an prospective open trial, IV and IA thrombolysis, thrombectomy, Telemedicine and Craniotomy for malignant stroke.

Fig 1: A CT of the head showed a large right cerebellar infarct with an oedema compressing the fourth ventricle.

Fig 2: A CT angiogram showed a total occlusion of the distal third of basilar artery (white arrow) at a 12-13 mm section. Both post. com. art. were patent. The vertebrate arteries were irregular and had focal narrowing which was suspicious for a dissection, most notably on the left, which was the dominant vessel.

Fig 3a: An angiogram done during thrombectomy showed a total occlusion at the top of the basilar artery (white arrow) at a 12-13 mm section. The vertebrate art. were irregular and had focal narrowing confirming prior suspicion for an dissection in the vessels ([a1] read arrow), particularly in the left dominant vessel.

Fig 3b. Thromby removed from the basilar artery during thrombectomy.

Fig 3c: A repeated angiogram after thrombi removal showed reestablished blood flow in the basilar artery as well as a normal blood flow in both post. cerebal arteries (arrow).

Fig 4: An MRI of the head (DWI) 12 days after initiation of symptoms reviled an extensive infarction (diffusion sequences) in nearly all of the right cerebellar hemisphere and sings of surgery. Also seen were small and diffuse infarctions in the left cerebellum, spotty infarction in the brainstem, and infarction in the right cerebellar peduncle and small on in the left thalamus.