Abstract Number ‐ 118: Compressive Vertebrobasilar Dolichoectasia: A Rare Etiology of Acute Pontine Ischemic Stroke Undeterred by Anticoagulation

Abstract

Introduction Dolichoectasia is a term used to describe dilated, elongated and tortuous arteries due to defects within the medial layer of their walls secondary to loss of elasticity. Multiple pathophysiological processes might lead to the development of dolichoectatic vessels, and activation of metalloproteinases and irregular turbulent blood flow seem to cause irreversible disruption of the internal elastic lamina. Consequences often include mass effects and ischemic and hemorrhagic stroke. Blood flow within dolichoectatic arteries is turbulent predisposing to thrombus formation with resultant ischemic strokes. Ideally, with optimal anticoagulation therapy, such strokes can be prevented. However, in rare instances, they can still occur despite anticoagulation, likely due to direct compression of pontine perforators from dolichoectasias or persistent turbulent flow. Methods Case report Results A 66‐year‐old woman with hypertension, diabetes mellitus, atrial fibrillation (taking warfarin at home), and left‐sided trigeminal neuralgia due to compressive left vertebrobasilar dolichoectasia with a focal fusiform aneurysm, presented with transient dysarthria and lightheadedness lasting for less than an hour. MRI brain did not show any acute pathology. CTA head showed worsening left vertebrobasilar dolichoectasia with transitional fusiform aneurysm (24 mm in diameter) with mass effect on the anterior part of the pons and lower midbrain. Next day, the patient developed dysarthria and right‐sided weakness, and a repeat MRI brain showed a left acute paramedian pontine infarct. Warfarin was discontinued, and the patient was started on a heparin drip and later transitioned to Apixaban. Eventually, a diagnostic cerebral angiogram and surpass stent placement within the aneurysm were attempted which went uneventful and the flow through the aneurysm regularized. The patient was eventually discharged home on Apixaban and Prasugrel with interval follow‐up. Conclusions Compression of perforating vessels supplying brainstem structures, branching off the pathologic vertebrobasilar dolichoectasia is a rare etiology of acute pontine ischemic stroke, not with standing the anticoagulation. It warrants immediate neurosurgical intervention to optimize blood flow and prevent a recurrence.