35 year old woman with headache,nausea and vomiting

 

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Doctor's Information

Name : Hamidreza
Family : Haghighatkhah
Affiliation :Radiology department,Shohada Tajrish Hospital,SBMU
Academic Degree : Associate professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Razmin Aslani

 

Case Section

Neuroradiology

 

Patient's Information

Gender : Female
Age : 35

 

Clinical Summary

35 year old woman with headache,vertigo,nausea and vomiting

 

Imaging Findings

There is dense content with in basilar artery without obvious infarct in primary CT scan (first 2 images) but large cerebellar infarct in CT scan of 2 days (3rd and 4th images).

 

Differential Diagnosis

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Final Diagnosis

Basilar artery thrombosis

 

Discussion (Related Text)

Basilar artery thrombosis can be detected on CT scans by the appearance of hyperdense clot within this artery and variable ischemic hypodensity in the brain stem, cerebellum, thalami, and PCA territory. Careful clinical correlation is recommended when the diagnosis of basilar artery thrombosis is suggested on the basis of non-enhanced CT findings, because the appearance of basilar artery thrombosis in some older patients may be mimicked by increased arterial density related to atherosclerotic calcification. The diagnosis of basilar artery thrombosis may be confirmed with CT angiography or MRA or, more commonly, with conventional catheter angiography. Basilar artery thrombosis may produce complete or incomplete occlusion of the basilar artery with variable visualization of intraluminal thrombus.(1) Acute basilar artery occlusion, whether from primary atheromatous disease or embolism, is a devastating event, likely to result in significant morbidity and mortality.Reversal of hyperdense artery sign (both in middle cerebral and basilar arteries) has been associated with improved outcomes(2) Patients with acute occlusion of the basilar artery will present with sudden and dramatic neurological impairment, the exact characteristics of which will depend on the site of occlusion.The earliest sign on CT is a hyperdense basilar artery (the basilar artery equivalent of the hyperdense MCA (middle cerebral artery sign). In patients presenting cerebellar or brainstem signs the presence of hyperdense basilar have high likelihood of having basilar thrombosis.A high index of suspicion is needed in the correct clinical setting as the diagnosis can easily be missed (often only present on 1 or 2 slices) and delayed diagnosis in these cases means a rapidly downhill course and death. Some have advocated a value 60HU as being probably a reasonable 'ball park' upper limit of normal in patients with a low index of suspicion, although clearly this will miss many acute thrombi. Probably a better approach is to compare the basilar artery to the internal carotid artery density, preferably on the same slice. A significant difference is concerning.further assessment with angiography (CTA, MRI or catheter angiography) is required, which will demonstrate a filling defect within the basilar artery. If the vessel is not recanalised expediently posterior circulation infarction in the brainstem, thalami and cerebellum will develop, with the usual CT and MRI signs.(3)

 

References

1-John R.Haaga , CT and MRI of the whole body , fifth edition 2009 , page 230-231 2-Hyperdense Basilar Artery Sign on Unenhanced CT Predicts Thrombus and Outcome in Acute Posterior Circulation Stroke.Gregory V. Goldmakher,Erica C.S. et al.Stroke. 2009; 40: 134-139 3-Acute basilar artery occlusion.Dr Frank Gaillard and Dr Donna D'Souza et al.read it at http://radiopaedia.org/articles/acute-basilar-artery-occlusion

 

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