Looking Twice the Wrong Way: The Challenge of Diagnosing Acute Basilar Artery Occlusion
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Looking Twice the Wrong Way: The Challenge of Diagnosing Acute Basilar Artery Occlusion Erika L. Weil1 , Lorenzo Rinaldo2 and Alejandro A. Rabinstein1* © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
Basilar artery occlusions (BAOs) represent only 1–4% of all ischemic strokes [1, 2]; however, early recognition is imperative due to the potential for a devastating outcome. It is well known that BAO can present with a constellation of neurologic deficits. While conjugate eye deviation (CED) is most often associated with large hemispheric strokes [3, 4], vertebrobasilar disease can also cause oculomotor abnormalities due to brainstem ischemia [1, 2, 5]. We describe a patient who presented with fluctuating symptoms and alternating CED in the setting of basilar artery thrombosis. A 52-year-old right-handed man presented to an outside hospital after developing acute onset of left-sided hemiparesis and dysarthria. There was no recent trauma, but he had lifted a heavy object prior to symptom onset. Medical history included hypertension, ischemic cardiomyopathy, and recent unprovoked pulmonary embolus not on anticoagulation. Head computed tomography (CT) revealed no acute intracranial abnormalities. A CT angiogram (CTA) of the head and neck demonstrated diminutive flow in the intracranial segment of the right vertebral artery but otherwise patent vasculature. Incidentally, a left gaze deviation was noted on imaging (Fig. 1a, b). He received intravenous alteplase approximately two hours after symptom onset. While preparing to transfer to our institution for post-thrombolytic cares, he became acutely hypotensive with a systolic blood pressure of 70, developed right gaze deviation, flaccid right hemiplegia, and muteness. No seizure activity was witnessed. A repeat, emergent non-contrast head *Correspondence: [email protected] 1 Departments of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Full list of author information is available at the end of the article
CT showed no evidence of hemorrhage. The new rightward gaze deviation was seen on imaging (Fig. 1c). He was transported to our institution for further assessment. Examination on arrival demonstrated conjugate eye deviation to the right with impaired left horizontal gaze, severe dysarthria without aphasia, right hemiplegia, mild left hemiparesis, and left hemiataxia. Following fluid bolus and being kept flat, blood pressure improved and he demonstrated improvement in symptoms. Repeat CTA of the head and neck re-demonstrated the distal right vertebral artery occlusion and new non-occlusive thrombus throughout the basilar artery (Fig. 1d). Patient was taken for endovascular intervention. Immediately prior, his repeat examination demonstrated resolved ophthalmoplegia and bilateral saccadic eye movements with horizontal gaze. Cerebral angiogram showed nonocclusive thrombus spanning from the proximal basilar artery to the apex. The basilar artery was successfully recanalized
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