Dolechoectatic Basilar Artery

Case #17:MRI: dolichoectatic basilar artery

CC: Left hand numbness and tingling.

HX: 66 y/o RHM with CAD, HTN and a history of a single episode of left sided weakness with associated "visual" problems in 3/92. There were no associated problems with speech. These symptoms slowly resolved over 2 months. He had been doing well until approximately 6:45AM on the date of exam when, while eating a donut, suddenly developed mild left hand numbness and tingling. He then tried to get up to go to the restroom and felt "off balance(vertigo)," and nauseated. He then vomited and developed a mild bioccipital and bifrontal headache. He went to a local ER and was found listing toward the left. He complained of nausea whenever sitting up. BP was 210/102. He was transferred to UIHC.

PMH: HTN, CAD(s/p CABG 1988), s/p AAA repair, s/p back surgery, COPD

FHX: DM, CAD, no stroke

SHX: 3-4cigarettes/week. Previously a heavy smoker. no hx of ETOH/drug abuse. Lives alone. Retired truck driver.

MEDS: Lotensin, Lasix, KCL, Proventil, Amitriptyline

EXAM: 36.1C, 79BPM, BP 178/87, 17RPM.

MS: Alert and oriented to person, place, time. Speech: dysarthric but fluent. Comprehension, naming, repetition were intact. Moderately distressed.

CN: Conjugate gaze paresis to the right. Horizontal nystagmus on leftward gaze and vertical nystagmus on upward gaze, OU. Pupils: 3/4 decreasing to 2/3 on light exposure. Diminished gag on left,

MOTOR: initially full strength. SENSORY: decreased PP and light touch in left hand. COORDINATION: decreased RAM bilaterally. Poor FNF and HKS on left.

The general physical exam was unremarkable except for great toe cyanosis, bilaterally.

LABS: Na 140, K 4.5, BUN 26, CR 1.6, ESR 88, WBC 8.0, Hgb 14.7, Hct 46, Plt 219k.

HCT 11/1/92: Hyperintense round lesion, 18mm in diameter, in the left cerebellopontine angle. The lesion enhanced with IV contrast. There was diffuse cerebral atrophy. The lesion was felt to represent an aneurysm, meningioma or AVM.

MRI brain, 11/1/92 and 11/3/92 revealed a fusiform aneurysm of the basilar artery. The 11/3/92 study showed decreased T2 signal about the perimeter of the aneurysm; this was felt to represent hemorrhage. There was also increased T1 signal in the left cerebellum thought to represent infarct.

COURSE: The patient developed fever, left hemiparesis with right lower facial weakness and meningismus 2 days after admission. CSF: gluc 23, prot 143, WBC 1910, RBC 460, Neutrophil 1757. Cultures/GS negative. He was treat with Ampicillin and Ceftriaxone. His neurological condition worsening and a second MRI revealed more brainstem ischemia. A DNR status was obtained. He then developed aspiration pneumonia and died.