A Case of Stroke and Blindness

Abstract

An 82-year-old woman presented to the emergency department with a one-day history of vomiting and vertigo. She did not have a headache, neck pain or history of recent trauma. She reported jaw pain two months prior to presentation, which had spontaneously resolved.Her past medical history included type 2 diabetes mellitus, hypothyroidism, and hypercholesterolemia. She was taking metformin 500 mg twice daily, levothyroxine 25 mcg daily, simvastatin 40 mg daily and acetylsalicylic acid (ASA) 81 mg daily.She was a lifelong non-smoker. Physical ExaminationOn examination, she had right-beating nystagmus on right gaze. Power was normal with the exception of grade 4/5 strength in her left deltoid. There was finger-to-nose dysmetria on the left side, dysdiadochokinesia with the left hand, and an unsteady gait. The remainder of her physical exam was unremarkable. NEURORADIOLOGY: DR. LEEMagnetic resonance imaging (MRI) demonstrated bilateral posterior inferior cerebellar artery distribution infarcts (larger on the left) with diffusion restriction, as well as two small right pontine perforator infarcts. The 3D phase contrast magnetic resonance angiography (MRA) showed absence of identifiable flow in both distal vertebral arteries, and T2 MRI showed an absence of intradural flow void in the left vertebral artery ( Figure 1). Digital subtraction angiography (DSA) was not performed, considering the patient's age and the presence of a stroke. Collateral circulation to the basilar and vertebral arteries was presumed to be from both posterior communicating arteries, which were of reasonable calibre. CASE PRESENTATION: DR. MATTIAThe patient was admitted to hospital. Aspirin was discontinued, and she was started on clopidogrel (75mg daily). Investigations did not reveal a cardiac source for her stroke.