(Kiosk 4) Posterior Circulation Infarcts Secondary to Basilar Artery Occlusion Progression: A Case Report

Case Diagnosis: Posterior Circulation Infarcts Secondary to Basilar Artery Occlusion Progression: A Case Report

Case Description or Program Description: 65-year-old female with past medical history of hypertension presented with three days of right ear fullness, decreased hearing and intermittent vertigo. Her family doctor prescribed antibiotics for presumed ear infection with no relief. Patient then presented to the emergency room for worsening symptoms with new onset difficulty ambulating. CT Head without contrast showed acute stroke in the right middle cerebellar peduncle and pons. CT angiography of the head and neck revealed basilar artery occlusion (BAO).She was started on dual antiplatelet therapy. Nonetheless, symptoms worsened and MRI brain without contrast showed scattered acute ischemic strokes throughout posterior circulation including bilateral cerebellum, right pons/midbrain and left PCA territory. Patient was started on heparin drip then transitioned to oral antiplatelet.

Setting: Inpatient rehabilitation facility

Assessment/Results: Following management, the patient was downgraded from neurology and admitted to acute inpatient rehabilitation for rehab of ataxia and motor deficits. The patient showed functional improvement and was discharged on a treatment of antiplatelet and aspirin.

Discussion (relevance): BAO is an infrequent form of acute stroke and can initially present similar to an inner ear dysfunction leading to misdiagnosis. In rare instances, such as seen in our patient, BAO can continue progressing to the posterior circulation causing further symptoms. Literature has shown that early recanalization is the most important prognostic factor for good outcome, however, reliable data is still lacking. Therefore, it is not uncommon to see patients treated conservatively as this patient.

Conclusions: Early diagnosis of BAO and appropriate therapy should be initiated to prevent life-threatening brainstem complications. Although management is still debated, cases like these show that more research is needed to set standardized treatment guidelines in regards to using pharmacologic agents versus mechanical thrombolysis, especially in those hospitals which may not be equipped for the latter.