Presentation
The patient presents with an acute severe headache and vertigo. She collapses in the emergency department and is intubated.
Patient Data
Multiparametric MRI brain reveals extensive hyperacute posterior circulatory infarction of the cerebellar hemispheres, vermis, right occipital lobe, right thalamus, medial right temporal lobe, left ventromedial thalamus and head of the right caudate nucleus. There is variable diffusion restriction and associated reduced average diffusivity on ADC mapping with negative T2 FLAIR imaging. This involves bilateral posterior inferior cerebellar arteries (PICA), bilateral superior cerebellar arteries (SCA), and bilateral posterior cerebral arteries (PCA).
There is additionally suspected infarction of the left hemi-pons (basilar artery) with vague reduced diffusivity on ADC mapping.
The head of the right caudate nucleus infarction would be consistent with lateral lenticulostriate perforator involvement.
There are no obvious features to suggest vertebral or basilar dissection on these sequences.
Case assistance: Dr S.Daya
Case Discussion
There is extensive early hyperacute (0-6 hours) non-hemorrhagic infarction as demonstrated above with negative T2 FLAIR imaging. The study was prematurely curtailed due to the instability of the patient during image acquisition and an intra and extracranial angiogram could not be completed.
The patient suffered a cardiac arrest and resuscitation was unsuccessful.
The multifocal sites of hyperacute infarction suggest a possible embolic etiology.
The MRI findings and the rapidity of the patient's clinical deterioration after presentation to the emergency department were unexpected.
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