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Clinical Program for Cerebrovascular Disorders Mount Sinai Medical Center. Stroke Associated with Intracranial Vascular Disease and A Discussion of WASID (The Warfarin-Aspirin Symptomatic Intracranial Disease Trial) Clinical Case Presentation Clara Raquel Epstein, MD Fellow.
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Stroke Associated with Intracranial Vascular Disease and A Discussion of WASID
(The Warfarin-Aspirin Symptomatic Intracranial Disease Trial)
Clinical Case Presentation
Clara Raquel Epstein, MD Fellow
On initial examination the patient was found to have a left facial droop, a mild left upper extremity pronator drift, decreased rapid arm movement on the left and proximal left lower extremity weakness of 4/5. Pin-prick and proprioceptive sensory deficits were evident in a stocking glove distribution. The patient demonstrated a left hemiparetic gait.
The patient was admitted to the Stroke Unit for further diagnostic evaluation and intervention. A non-contrast head CT was obtained on admission which revealed hypodensities in the left internal capsule and in the right Globus Pallidus compatible with ischemia. It was suggested that this could represent lacunar strokes.
He was initially started on aspirin, lisinopril, simvistatin and glyburide. On hospital day #3 the patient was then started on heparin per protocol and the aspirin was discontinued. Coumadin was then started on hospital day #7.
to Initially the patient was doing well with minimal neurologic impairment with the exception of a left visual field cut. The patient was started on Dilantin for seizure prophylaxis. However, the patient’s course in the stroke unit was significant for progressive neurologic deterioration with a progression of left hemiparesis and left facial palsy despite steroid therapy. In addition, the infectious disease service was consulted for a positive RPR titer and a decision to treat the patient with a three week course of Penicillin IM was initiated.
Further evaluation included MRI and MRA with diffusion and cerebral angiography. The MRI/A revealed increased signal on flair and diffusion in the right basis pontis indicating acute infarction. This area corresponds to the right posterior cerebral artery narrowing which was visualized on the MRA. There also appeared to be narrowing of the distal vertebral artery at its junction with the basilar artery. In addition, some stenosis of the basilar artery appeared to be present.
The cerebral angiography showed evidence of atherosclerotic narrowing of the distal left vertebral intradural segment. The luminal caliber is less than what would be expected for normal anatomic tapering. The degree of stenosis is approximately 60% as compared with the normal intradural vertebral artery proximally. Mild atherosclerotic narrowing of the distal right vertebral artery intradural portion. The degree of stenosis is mild and approximately 40% as compared with the vessel proximally.
A small focal smooth atherosclerotic plaque within the midbasilar artery at the right lateral wall producing no significant narrowing of the vessel lumen was also seen. Mild atherosclerotic change within the bilateral posterior cerebral arteries without significant focal stenosis was seen. Minimal atherosclerotic change of the right internal carotid artery origin was also seen.
Funding Source: National Institute of Neurological Disorders and Stroke
Coordinating Center: Emory University
Marc I. Chimowitz, MBChB
Associate Professor of Neurology
Emory University Hospital
% stenosis = (1-(D stenosis/ D distal)) x 100%