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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 48-49

Acute Bilateral Cerbellar and Brain Stem Infarction in The Territory of The Medial Branches of Posterior Inferior Cerebellar Arteries


1 Senior Resident, Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
2 Assistant Professor, Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
3 Associate Professor, Department of General Medicine, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India

Date of Web Publication11-Dec-2020

Correspondence Address:
Kalyan Kumar Saha
Senior Resident, Department of General Medicine, Indira Gandhi Institute of Medical Sciencs, Sheikhpura, Patna -14
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


We repot a rare case of acute bilateral cerebellar and brain stem infarction confined to the territory of the medial branches of the posterior inferior cerebellar arteries. The diagnosis was based on clinical and radiological examination.
Case Description A known hypertensive 66-year old female presented with sudden onset of headache, vertigo, followed by brief loss of consciousness. Cranial computed tomographic scan showed edema in bilateral medial cerebellar zone and brainstem suggestive of acute ischemic infarction. On examination the patient showed mild dysarthria, dysequilibrium with retropulsion, symmetrical bilateral horizontal gaze evoked nystagmus on lateral gaze, and marked gait ataxia with brain stem signs, followed by marked vertigo that was induced by motion.
Her blood pressure was recorded to be 190/110mmHg in right arm. The patient improved with conservative therapy, including intravenous administration of mannitol.
Conclusions
We suspect that our patient likely had initial transient occlusion of the right vertebral artery at the origin of the right posterior inferior cerebellar artery, which probably gave rise to the bilateral medial branches of posterior inferior cerebellar arteries. This caused infarction in the territory of the medial branches on both sides with brain stem signs. Such an unusual pattern of cerebellar infarction accompanied by brain stem sign posed a diagnostic challenge in the ward, and correct diagnosis was facilitated by cranial computed tomography.

Keywords: cerebellar infarction ; cerebellar oedema ; computed tomography


How to cite this article:
Saha KK, Kumar A, Mishra AK, Kumar S, Kumar P. Acute Bilateral Cerbellar and Brain Stem Infarction in The Territory of The Medial Branches of Posterior Inferior Cerebellar Arteries. J Indira Gandhi Inst Med Sci 2017;3:48-9

How to cite this URL:
Saha KK, Kumar A, Mishra AK, Kumar S, Kumar P. Acute Bilateral Cerbellar and Brain Stem Infarction in The Territory of The Medial Branches of Posterior Inferior Cerebellar Arteries. J Indira Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 7];3:48-9. Available from: http://www.jigims.co.in/text.asp?2017/3/2/48/303148




  Introduction Top


Cerebellar infarction is not an uncommon autopsy finding, the frequency of which varies from 1.1% to 4.2% in autopsy series[1]. The majority of infarcts occur in the territories of the posterior inferior cerebellar artery (PICA) and superior cerebellar artery[1]. Among PICA infarcts, only a few clinicopathological[2],[5]and clinicoradiological[3] studies of infarcts in the PICA territory distal to its medullary branches have been reported, and patients with bilateral cerebellar infarcts primarily confined to the territory of the medial branches of both PICAs have been reported in only few articles. We describe a clinicoradiological study of a patient with such bilateral cerebellar infarcts , the diagnosis of which was facilitated by Computed Tomographic Scan of the brain.


  Case Report Top


A 66-year-old woman with long-standing hypertension, developed sudden onset of rotatory vertigo on April 14,2017, while walking in the courtyard, followed by an inability to keep standing and a brief loss of consciousness. On admission to this hospital on the same day, she was disoriented but became mentally alert on the next day. A cranial computed tomographic scan (CT) showed edema in bilateral cerebellar lobe and in brain stem, suggestive of ischaemic infarct. Family history was noncontributory. The pertinent findings on general physical examination consisted of blood pressure of 190/110 mm Hg, regular pulse rate of 60 beats per minute, and normal CVS examination. Neurologically the patient was awake but was mentally slow, disoriented in time, and mildly dysarthric. Extraocular movements were full, and symmetrical bilateral horizontal gaze-evoked nystagmus on lateral gaze was observed without diplopia. Dysdiadochokinesis was mild in the right hand and moderate in the left hand. Muscle strength, deep tendon reflexes, and sensation were preserved. Babinski’s sign was not present. Gait tested 7 days after admission revealed that the patient was unable to keep standing with her feet together, instead falling backward. She walked with feet 15 cm apart and was unable to perform a tandem gait. Laboratory data on admission showed normal values of blood cell count, blood chemistry, and urine, except for white blood cell count of 12 4OO/mm3, C-reactive protein of 2.0mg/dL, and serum lactic dehydrogenase of 412 IU/L. ECG suggested LVH. 2D- ECHO showed concentric LVH. On treatment, the patient became able to ambulate with a markedly wide-based gait, complicated by frequent episodes of nausea, vomiting, and vertigo associated with movement of his body, and both horizontal and rotatory gaze-evoked nystagmus on lateral gaze to the right side. He was discharged 7 weeks after admission with a mildly wide-based gait and without other signs. The patient denied for Magnetic Resonance Imaging Brain ,Digital Substraction Angiography, Computed Tomographic Angiography.


  Discussion Top


Cranial CT showed that the bilateral cerebellar infarct observed in our patient was confined to the territory of the medial branches of the bilateral PICAs,which is rarely reported. The occurrence of cerebellar infarcts confined to this arterial territory on both sides as observed in our patient is unusual and has not been well documented previously. Regarding the pathogenesis of this unusual cerebellar infarct, several possibilities were considered, as follows: (A) both PICAs arose from the basilar artery; (B) both medial branches of the PICAs arose from the PICA on one side; (C) two emboli occurred in the PICAs, one to each side; and (D) pressure effects caused by a large PICA infarct on one side compressed arteries in the cerebellar cistern between the two sides, inducing a smaller infarct on the other side.. Our patient had brain stem signs on transfer to our care, although She showed involvement of the cerebellum in the bilateral PICA territory. This unusual distribution and presentation of lesions as a result of vertebrobasilar ischemia was a more likely possibility, which was also consistent with the sudden onset of symptoms and the gradual improvement of neurological abnormalities in this patient. The case of acute bilateral cerellar infarction in the territory of the medial branches of posterior inferior cerebellar arteries has also been reported by Tada et. al.[4]


  Acknowledgments Top


We are sincerely thankful to the entire faculties of the department of general medicine, neurology and radiology of IGIMS, PATNA for their invaluable comments and encouragement.



The above CT scan showed bilateral cerebellar and brain stem edema as marked by arrow.



 
  References Top

1.
Amarenco P. The spectrum of cerebellar infarctions. Neurology, 1991;41:973-9.  Back to cited text no. 1
    
2.
Duncan GW, Parker SW, Fisher CM. Acute cerebellar infarct in the PICA territory. Arch Neurol. 1975;32:364-8.  Back to cited text no. 2
    
3.
Amarenco P, Roullet E, Hommel M, Chaine P, Marteau R. Infarction in the territory of the medial branch of the posterior inferior cerebellar artery. J Neurol Neurosurg Psychiatry. 1990;53: 731-735.  Back to cited text no. 3
    
4.
Tada Y et al. stroke. 1994;25:686-8.  Back to cited text no. 4
    
5.
Amarenco P, Hauw JJ, H6nin D, Duyckaerts C, Roullet E, Laplane D, Gautier JC, Lhermitte F, Buge A, Castaigne P. Les infarctus du territoire de l’artere ce>6belleuse postSrio- infgrieure. Etude clinico-pathologique de 28 cas. Rev Neurol (Paris). 1989;145: 277-86.  Back to cited text no. 5
    




 

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