Perfusion- and Diffusion-Weighted MR Imaging–Guided Therapy of Vertebral Artery Dissection: Intraarterial Thrombolysis through an Occipital Vertebral Anastomosis
Lucas Restrepoa,
Gustavo Pradillac,
Rafael Llinasa and
Norman J. Beauchampb
a Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland
b Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
c Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
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FIG 1. A 34-year-old woman with sudden onset of ataxia and dysarthria was transferred to our institution because of neurologic degeneration 24 hours after the beginning of symptoms.
A and B, T2-weighted images obtained 39 hours after symptom onset, revealing foci of hyperintense signal involving the right side and paramedial regions of the midpons.
C and D, Diffusion-weighted image (C) also reveals foci of hyperintense signal. Apparent diffusion coefficient maps (not shown) ruled out T2 shine-through. Perfusion-weighted image (D) shows patchy regions of oligemia involving the cerebellum and pons. Comparison of C and D shows a perfusion-diffusion mismatch.
E and F, Oblique- (E) and lateral-view (F) sequential-phase digital subtraction angiograms obtained 43 hours after symptom onset show posterior circulation opacification through an occipital vertebral anastomosis. Note the abrupt end of the distal basilar artery and virtual absence of cerebellar blush.
G, Lateral-view digital subtraction angiogram of the vertebrobasilar circulation obtained after intraarterial thrombolysis with rt-PA. Although the distal basilar artery remains occluded, a substantial improvement of the cerebellar blush is appreciated.
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