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Neurology (Expert Forum)
vertebral artrey stroke
Answered by
CCFNeuroMD JT, MD - Neurology/Epilepsy, Neurology/General
Cleveland - OH
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vertebral artrey stroke
by ransari, Apr 23, 2008 09:47AM
HI THERE,
I m first yr resident in medicine I have a patient who is presented wid folowing :
33yrs old male (ex alcohol abuser ,quit 2yrs ago)known hypertensive for two years (on tab Ramipace)presented with history of nausea, vomiting headache,diplopia, inability to swallow. in his past history he has had MI 2yrs ago and was found to have thrombus in left ventricle at that time and was on tab warfarin 5mg/d since than his lipid profile at that time showed Hypercholetestrolemia and is on statins since 2years (currently lipid profile is in normal range).his family history is insignificant and there is no family history of hypertention ,diabetes mellitus,
O/e he has left 5th, 6th, 7thcranial nerve palsies, palsy of 9th and 10 cranial nerves. Along with this there’s also asymmetry of pulses in Right and left radial pulses.
Imaging CT scan was normal,
Angiogram of vertebral and carotids showed occlusion of left vertebral artery along with the intracranial portion rest was normal. Kindly help me out what could be cause of stroke in this patient and how should I manage this patient. I am suspecting Vasculitis as a cause please help me.
Thanks.
I m first yr resident in medicine I have a patient who is presented wid folowing :
33yrs old male (ex alcohol abuser ,quit 2yrs ago)known hypertensive for two years (on tab Ramipace)presented with history of nausea, vomiting headache,diplopia, inability to swallow. in his past history he has had MI 2yrs ago and was found to have thrombus in left ventricle at that time and was on tab warfarin 5mg/d since than his lipid profile at that time showed Hypercholetestrolemia and is on statins since 2years (currently lipid profile is in normal range).his family history is insignificant and there is no family history of hypertention ,diabetes mellitus,
O/e he has left 5th, 6th, 7thcranial nerve palsies, palsy of 9th and 10 cranial nerves. Along with this there’s also asymmetry of pulses in Right and left radial pulses.
Imaging CT scan was normal,
Angiogram of vertebral and carotids showed occlusion of left vertebral artery along with the intracranial portion rest was normal. Kindly help me out what could be cause of stroke in this patient and how should I manage this patient. I am suspecting Vasculitis as a cause please help me.
Thanks.
Doctor's Answer
by CCFNeuroMD JT, MD, Apr 29, 2008 10:00AM
, Apr 29, 2008 10:00AM
To: ransari
Dear ransari,
Thank you very much for your question. I am happy to address the issues that you pose, although it is important that you recognize that my impression is based entirely on the information you have provided in your posting and is by no means a replacement for an office visit with a neurologist. Diagnosis is contingent on detailed history and physical exam and as such, the following information should be considered solely for educational purposes.
It sounds like you have a very interesting patient, indeed! In such a complex case, it is definitely very important to be thorough. You have not mentioned an MRI of the brain and unless there is a contraindication to do so (i.e. pacemaker, etc), I would certainly conduct and MRI/MRA of the brain with and without contrast to evaluate for any subtle enhancement or mass lesions which might suggest leptomeningeal carcinomatosis, brain tumor, metastases, etc. Although the diagnosis of CNS vasculitis is often made by angiogram, a normal cerebral angiogram cannot exclude the diagnosis. Other considerations include MS, a paraneoplastic syndrome and neurosarcoidosis. Have you conducted basic labs such as ESR, CRP, CBC, CT chest/abdomen/pelvis (to screen for malignancy), metabolic panel, etc? I would also conduct a lumbar puncture and send the CSF for cytology, flow cytometry, oligoclonal bands, IgG index, routine analysis. A serum paraneoplastic panel (including anti-Hu, anti-CV2, anti-Yo, anti-Ri, anti-CAR, anti-Ma, anti-Ta and anti-Zic4 antibodies) can be sent off to Mayo Clinic as well; it is important that paraneoplastic syndrome may be detectable years before the patient has any evidence of malignancy.
You mention that your patient has hypertension. have you looked at the patient's renal arteries to evaluate for renal artery stenosis? Evidence of such may be suggestive of a systemic vasculitis with CNS manifestations. If this is the case, you can biopsy the renal arteries to arrive at a diagnosis which carries a much lower risk than brain biopsy. Ultimately, you may need to refer your patient for brain biopsy in order to rule out CNS vasculitis if all other testing is fruitless.
We see these types of patients all the time at the Cleveland Clinic and my best advice to you is to refer your patient to a neurologist who can conduct a more thorough exam and determine which testing is most appropriate. The above is simply a list of potentially appropriate tests but as you know, it is impossible to offer a diagnosis and plan of care without having the opportunity to take a history and examen the patient. Thank you very much for this interesting case, and good luck with arriving at a diagnosis.
JBT, MD
Thank you very much for your question. I am happy to address the issues that you pose, although it is important that you recognize that my impression is based entirely on the information you have provided in your posting and is by no means a replacement for an office visit with a neurologist. Diagnosis is contingent on detailed history and physical exam and as such, the following information should be considered solely for educational purposes.
It sounds like you have a very interesting patient, indeed! In such a complex case, it is definitely very important to be thorough. You have not mentioned an MRI of the brain and unless there is a contraindication to do so (i.e. pacemaker, etc), I would certainly conduct and MRI/MRA of the brain with and without contrast to evaluate for any subtle enhancement or mass lesions which might suggest leptomeningeal carcinomatosis, brain tumor, metastases, etc. Although the diagnosis of CNS vasculitis is often made by angiogram, a normal cerebral angiogram cannot exclude the diagnosis. Other considerations include MS, a paraneoplastic syndrome and neurosarcoidosis. Have you conducted basic labs such as ESR, CRP, CBC, CT chest/abdomen/pelvis (to screen for malignancy), metabolic panel, etc? I would also conduct a lumbar puncture and send the CSF for cytology, flow cytometry, oligoclonal bands, IgG index, routine analysis. A serum paraneoplastic panel (including anti-Hu, anti-CV2, anti-Yo, anti-Ri, anti-CAR, anti-Ma, anti-Ta and anti-Zic4 antibodies) can be sent off to Mayo Clinic as well; it is important that paraneoplastic syndrome may be detectable years before the patient has any evidence of malignancy.
You mention that your patient has hypertension. have you looked at the patient's renal arteries to evaluate for renal artery stenosis? Evidence of such may be suggestive of a systemic vasculitis with CNS manifestations. If this is the case, you can biopsy the renal arteries to arrive at a diagnosis which carries a much lower risk than brain biopsy. Ultimately, you may need to refer your patient for brain biopsy in order to rule out CNS vasculitis if all other testing is fruitless.
We see these types of patients all the time at the Cleveland Clinic and my best advice to you is to refer your patient to a neurologist who can conduct a more thorough exam and determine which testing is most appropriate. The above is simply a list of potentially appropriate tests but as you know, it is impossible to offer a diagnosis and plan of care without having the opportunity to take a history and examen the patient. Thank you very much for this interesting case, and good luck with arriving at a diagnosis.
JBT, MD
