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Neurological Rehabilitation

Stroke from the petrous bone

(Kiosk 3) Stroke from the Petrous Bone

Saturday, November 18, 2023
12:00 PM – 1:30 PM CT

    Primary Author(s)

  • FM

    Fernando Martinez, MD

    Resident Physician
    Montefiore Medical Center/Albert Einstein College of Medicine PM&R Program
    New York, New York

    • Co-Author(s)

  • Ricardo J. Fuentes-Saavedra, MD

    Resident Physician
    Montefiore Medical Center/Albert Einstein College of Medicine PM&R Program
    New York, New York

  • AW

    Aye Mon Win, DO

    Attending Physiatrist
    Montefiore Medical Center
    Bronx, New York

Case Diagnosis: Left MCA (middle cerebral artery) stroke secondary to narrowing of bilateral cervical ICAs (internal carotid artery) due to an ill-defined soft tissue process at the skull base with periostial reaction at the surface of the clivus and erosion the skull base.

Case Description or Program Description: Pt is a 69 y.o. male with PMH of T2DM who was BIBEMS after his daughter found him on the floor on 1/18. Last known well prior night. In ED, they noted patient's inability to stand, right side weakness and right facial droop with expressive aphasia. Initial imaging noted left MCA territory CVA with ill-defined soft tissue process at the skull base causing moderate stenosis to cervical ICAs with corresponding perfusion delay.

Setting: Tertiary hospital care and Acute rehabilitation unit

Assessment/Results: Skull base pathology with initial differential of osteomyelitis, neoplasms or inflammatory process. Biopsy performed 1/27, although sample was low yield, malignancy was ruled out and cultures were positive for Staphylococcus and Prevotella; considered by ID as normal naso-pharyngeal flora, however treatment was still offered for osteomyelitis. Considered Steroid intervention as inflammatory response could be the cause of the active process.

Patient improved and was transferred to the inpatient rehabilitation unit on 02/13. Patient symptoms slowly improved, although was noted to have persistent tinnitus until 02/22 where clinical worsening noted as steroids were being tapered down. He experienced loss of consciousness and imaging noted worsening of ICAs stenosis. Transferred acutely to the ICU and requiring Endovascular intervention for stenting of ICAs.

Discussion (relevance): As described in Starsnick and Vaughan case series, non-neoplastic inflammatory process to the temporal bone presents with tinnitus and hearing loss; this is a rare pathologic process that features slow growth with minimal mass effect, to bony destruction that can mimic malignancy.

Conclusions: Unfortunate results of an inflammatory process lead this patient to severe deficits secondary to compression of bilateral ICAs.