Case 35 A 59-year-old man suffered from a mild isolated transient left brachiofacial sensorimotor hemisyndrome which remitted completely before he was admitted to our hospital for the first time. He had an extensive history of vascular events: 2 years prior to admission, he developed a transient ischemic attack (TIA) and a corresponding right-sided internal carotid artery (ICA) stenosis (70% according to NASCET criteria), which was subsequently treated with carotid endarterectomy (CEA) with patch angioplasty. Five months later, he suffered a brainstem infarction. Several chronic vascular risk factors were present: arterial hyper-tension, smoking, and elevated blood lipids. Cranial CT revealed no acute ischemic lesion. CT angiography (CTA) demonstrated extracranial moderate athero-sclerotic caliber alterations in the carotid arteries. The left vertebral artery (VA) was visualized at the mid part of the V2-VA with a minimal caliber. The right VA was hypoplastic and showed severe calcifications. Normal findings were seen in the intracranial anterior circulation. The basilar artery (BA) showed a reduced diameter and wall irregularities. The left V4-VA diameter corresponded to that of the BA and also a prominent posterior inferior cerebellar artery (PICA) was seen, whereas the right V4-VA had a severely reduced diameter (Fig. B35.1, Fig. B35.2, Fig. B35.3). Cerebral MRI revealed chronic small-vessel basal ganglia lesions and an additional right pontine ischemic lesion, but no acute lesions on diffusion-weighted sequences. MR angiography was not performed. TIA in the left middle cerebral artery (MCA) territory. Assumed left proximal VA occlusion and right VA hypoplasia. B-mode imaging revealed extended, mostly hyperechoic, bilateral plaques with predominance in the right carotid bifurcation. The right carotid bulb had a marked dilation with a bidirectional reduced flow, assumed to be caused by the patch angioplasty performed during CEA 5 years before. Normal flow signals were observed in the left distal ICA and in the right-side carotid arteries. Both V2-VA had small diameters (right 2.4 mm, left 2.2 mm). A stump signal was detected in the left V2-VA indicative of a distal occlusion before the origin of the PICA. The flow signal of the right V2-VA corresponded with an assumed hypoplasia (Fig. B35.4, Fig. B35.5, Fig. B35.6, Fig. B35.7). Both M1-MCA and A1-ACA had normal flow signals. On both sides, a prominent posterior communicating artery (PCoA) was detectable with a flow toward the posterior circulation. On the left side, an obvious retrograde P1-posterior cerebral artery (PCA) flow was observed. Both P2-PCA segments had almost normal flow signals. On the right side, the P1-PCA was not clearly detectable. Following the left retrograde P1-PCA into the distal BA the retrograde signal remained. Retrograde BA flow was confirmed and appeared more evident during insonation in the posterior coronal plane. Upon transforaminal insonation, the BA flow was also retrograde toward the probe with normal flow velocities (75/20 cm/s). The left V4-VA yielded a retrograde flow signal (53/13 cm/s), whereas the right V4-VA revealed a low antegrade flow (20/9 cm/s) (Fig. B35.8–Fig. B35.20; see also Video Left distal VA occlusion proximal to the PICA offspring. Right V4-VA hypoplasia. Retrograde BA and retrograde left V4-VA filling—at least up to the left PICA—via the left PCoA and left retrograde P1-PCA. Regular anterior circulation. Fig. B35.1 (A,B) MR T2-weighted images, axial plane, revealing lacunar pontine and basal ganglia infarction probably caused by small-vessel disease (arrows). Fig. B35.2 Extracranial CTA, coronal maximal intensity projection (MIP). Lumen reduction in both VAs with marked calcifications on the right side (arrowhead) and a markedly reduced diameter on the left side (arrow). Fig. B35.3 Intracranial CTA, 3D reconstruction. Note the narrow diameters of the vertebrobasilar arteries compared with the vessels of the anterior circulation. Communication of the anterior circulation with the BA head was seen on both sides (arrowheads). The BA revealed wall irregularities (arrows). A marked PICA was seen on the left side (large arrow) and a slim V4-VA was visualized on the right side (short arrow). Fig. B35.4 Extracranial duplex, longitudinal plane. Left: B-mode image. Right: Color-mode image. Note the widening of the carotid bulb after CEA with patch angioplasty.
Left Distal Vertebral Artery Occlusion and Right Vertebral Artery Hypoplasia with Retrograde Basilar Artery Flow
Clinical Presentation
Initial Neuroradiologic Findings
Suspected Diagnosis
Questions to Answer by Ultrasound Techniques
Neurosonologic Findings (Day 3)
Transcranial Duplex Sonography
B35.1).
Conclusion
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