This 47-year-old man had a right cerebellar hemispherectomy secondary to a large cerebellar stroke (bilateral posterior inferior cerebellar artery [PICA] infarcts, right greater than left).

Our patient was a previously healthy 47-year-old man who had sudden-onset dyspnea, nausea, diaphoresis, disequilibrium, and dysarthria. These events occurred in association with an acute myocardial infarction. A 2D echocardiogram showed a left ventricular ejection fraction of 55% and no intracardiac thrombi. Magnetic resonance imaging (MRI) of the brain showed bilateral PICA territory infarctions. A cerebral angiogram demonstrated an occluded right vertebral artery and near occlusion of the left vertebral artery. During the angiographic procedure, he experienced neurologic decline with disconjugate gaze and bradycardia.

Hospital course was complicated by obstructive hydrocephalus requiring placement of a drain and subsequent resection of cerebellar necrotic tissue. He also developed heparin-induced thrombocytopenia and was treated with plasmapheresis and lepirudin, a direct thrombin inhibitor. Since hospital discharge, he had no recurrent transient ischemic
attacks (TIAs) or strokes. He was rendered wheelchair bound and unable to walk due to marked ataxia. Follow-up magnetic resonance angiography (MRA) showed complete recanalization of the vertebral arteries. The underlying cause of his vascular events was determined to be polycythemia vera.