A case of vertebral artery dissection: a cerebellar chameleon in a young man
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CE - MEDICAL ILLUSTRATION
A case of vertebral artery dissection: a cerebellar chameleon in a young man Andrea Leonardo Cecchini1 · Rossella Cianci1 · Emilio Lozupone2 · Andrea Contegiacomo2 · Giovanni Gambassi1 Received: 19 September 2020 / Accepted: 28 October 2020 © Società Italiana di Medicina Interna (SIMI) 2020
A 48-year-old man, from Moldavia was admitted to our emergency unit complaining objective vertigo and a mild right-hand incoordination with a sudden onset in the previous 48 h. Prior to hospital referral, the patient had been evaluated with an out-patient vertebral-carotid Doppler ultrasound and a brain computerized tomography (CT) scan without contrast, which resulted negative. In the emergency room, a first neurological examination was negative. No dysarthria, no deficit of cranial nerves, no nystagmus, no sensory or motor deficits at limbs and no asymmetry of the upper-right limb during the nose–finger test were documented. Vital parameters were in the normal range. No information about his family history was available and he denied any use of illicit drugs or alcoholic beverages. No clear history of neck/head trauma or manipulation. A brain CT scan without contrast was performed and it documented two hypodense lesions within the right cerebellar hemisphere and the right medium cerebellar pedunculus (Fig. 1a). The lack of symptoms during an initial neurologic exam, his out-patient vertebral-carotid Doppler ultrasound which tested negative and the absence of any previous clear trauma or manipulation of the neck, initially led emergency room doctors to interpret the CT findings as inflammatory or neoplastic brain lesions, delaying the decision to perform CT angiography to rule out possible cervical artery dissection.
* Rossella Cianci [email protected] 1
UOC di Medicina Generale, Dipartimento di Scienze dell’invecchiamento, neurologiche, ortopediche e della testa‑collo, Fondazione Policlinico Universitario A. Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy
UOC di Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS - Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
2
To complete the diagnostic work-up, the patient was transferred to our ward. A thorough neurological examination was conducted. Objective vertigo and slight incoordination of the right hand have been documented. So, a magnetic resonance imaging (MRI) was performed. The MRI documented a hyperintense signal on FLAIR/T2-weighted images with a minimal mass effect on the fourth ventricle and a mild restriction of water diffusion on DWI image (Fig. 1b–f). No sign of hemorrhage on SWI sequence and faint peripheral incomplete contrast-enhancement on C+T1weighted images with a non-clearly rimless pattern (Fig. 1f) (not uncommon findings in recent ischemic lesions) were detected. Although the MRI findings could not be interpreted conclusively,
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