CASE REPORT A 29-year-old woman came to our emergency department with sudden onset of left sided mild motor weakness and Enzastaurin FDA headache. She complained that her headache was pulsatile in the right temporal region, not associated with nausea or vomiting, and developed 14 days prior to the onset of left-sided motor weakness. On admission, her initial blood pressure was 170/90 mmHg. She did not have any past history of head trauma, smoking,
diabetes, or cardiovascular disease. An initial head computed tomography (CT) scan did not show any evidence of the intracranial or subarachnoid hemorrhage. MRI was performed to find evidence of cerebral infarction. Diffusion-weighted imaging (DWI) showed a right-sided, acute pontine infarction (Fig. 1A). Time-of-flight (TOF) magnetic resonance angiography (MRA) showed luminal irregularities with mild stenosis of the vertebrobasilar artery (Fig. 1B), but the source image of TOF MRA showed a long-segmental, periluminal hematoma (Fig. 1C). Based on these findings, we diagnosed the patient as having extensive VBD with an intramural hematoma. Fig. 1 A. The initial diffusion-weighted imaging showing an acute infarction in the right sided ventral pons. B. Time-of-flight magnetic
resonance angiography showing the mild luminal irregularities in the vertebrobasilar arteries. C. A source image of time-of-flight … After 3 days, we performed high-resolution MRI for an evaluation of the extent and severity of VBD. TOF MRA showed multifocal severe stenoses without dilatation of the vertebrobasilar artery (Fig. 1D). On T1-weighted MRI, the eccentric intramural hematoma increased, involving the longer segment of the vertebrobasilar artery, when
compared to the initial MRI study (Fig. 1E). However, a follow up DWI did not show any new ischemic lesion and her symptoms were well controlled by medical treatment with an antiplatelet agent and anticoagulant during her hospitalization. She was discharged with a stable condition, and no aggravating signs of neurologic symptoms were observed during the last 5 months of follow-up. DISCUSSION Spontaneous dissection of the vertebral artery is a well-recognized cause of ischemic stroke in the vertebrobasilar circulation territory in young and middle-aged adults [2, 5]. Spontaneous intracranial VBD can manifest with various clinical symptoms, including subarachnoid hemorrhage, ischemic symptoms from impaired GSK-3 posterior circulation, or even local symptoms such as occipital headache and/or neck pain in young adults [1, 2, 8, 9]. Previous studies suggested angiographic findings of the VBDs: tapered narrowing or occlusion, aneurysmal dilatation, intimal flap, retention of contrast agent in the false lumen, and pearl-and-string sign [1, 2, 7, 8]. Pathognomonic findings of VBD on MRI are intramural hematoma or intimal flap. In contrast, the pearl-and-string sign is not considered a pathognomonic sign, but is rather a reliable finding [1].