On day two after onset, a magnetic resonance imaging (MRI) scan was performed. Transthoracic echocardiography could not identify any atrial thrombi or valvular pathologies. Electrocardiography showed intermittent atrial fibrillation with spontaneous conversion to sinus rhythm on the second day of hospitalization. The patient was treated with aspirin and statin as an embolic infarction could not be ruled out. Initial cranial computed tomography (CT) did not show any signs of cerebellar pathologies. National Institute of Health Stroke Scale (NIHSS) score was 9. The patient was clearly conscious with a Glasgow Coma Scale (GCS) of 15 but had a left-sided Wallenberg’s syndrome, right brachial weakness (M4), left central facial paresis, left lateral gaze nystagmus, dysarthria, bilateral dysmetria on finger-to-nose and heel-to-shin tests, and truncal ataxia so severe that the patient could not stand. Her medical history revealed cerebrovascular risk factors, that is, long year tobacco abuse, hypertension, and dyslipidemia. Case ReportĪ 74-year-old woman was initially seen in the emergency department of a peripheral hospital presenting with acute onset of headache, dizziness, and limb weakness. Surgical and clinical management strategies are briefly discussed. Herein we report about an intraoperative visualization of a bilateral thrombosis of the telovelomedullary segment of the PICA. A macroscopic surgical visualization of bilateral acute PICA thrombosis has not been reported to date. Therefore, in addition to the infarct distribution, angiography is the modality of choice for the diagnosis of occlusion. Due to its small diameter (about 2.5 millimeters), tomographic imaging of the PICA may be flawed by artifacts and limited by uncertainties. Complete Wallenberg’s syndrome is found in up to 15% of ischemic strokes in the PICA distribution. Depending on the site of occlusion, clinical manifestation varies widely, from lack of symptoms to a severe medullary and cerebellar picture. Unilateral posterior inferior cerebellar artery (PICA) thrombosis is the most frequent type of cerebellar infarction and accounts for approximately 2% of all ischemic strokes. The surgical access may offer surgical therapeutic options in a hyperacute occlusion, such as thromb-/embolectomy or bypass procedures.
After the insertion of an external ventricular drainage, the patient underwent urgent suboccipital decompressive craniectomy with removal of infarcted cerebellar tonsils, which allowed the bilateral visualization of the thrombosed telovelomedullary segments. Her Glasgow Coma Scale score dropped from 15 to 13, and cranial computed tomography revealed compression of the fourth ventricle with consecutive occlusive hydrocephalus. A 74-year-old woman was admitted to our department on day two of a bilateral PICA thrombosis with developing cerebellar infarction. However, bilateral PICA thrombosis is rare.
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