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A 35-year-old right-handed male chef reported three similar neurological episodes in the preceding 6 months. Each episode began with a paroxysm of sneezing. In the first, sneezing was followed by sudden onset dizziness, and then over a few minutes by double vision, left-sided paraesthesiae, left-sided weakness and then a severe left-sided headache, all resolving after a few hours. The second and third episodes, approximately 2 months apart, were less severe. During the second event, he also noticed his right pupil was bigger than the left. In the third episode, 6 weeks before his clinic visit, he developed several hours of ataxia and double vision, but no sensory or motor symptoms; this was followed by left-sided headache.
The patient underwent MRI brain and magnetic resonance angiography (MRA) of the cervical vessels (figure 1).
What does the imaging show?
The MRA shows a dissection of the proximal right vertebral artery, causing a stenosis and a pseudoaneurysm distal to the stenosis, with thrombus in the pseudo-aneurysm. The MRI brain also shows an arteriovenous malformation (AVM) in the right temporoparietal lobe.
What is the diagnosis? What would you do next?
The most likely diagnosis is recurrent ischaemic events due to a vertebral artery dissection, with subsequent embolisation from either the dissection or from thrombus in the pseudoaneurysm. Pseudoaneurysms develop when haemorrhage into the blood vessel wall separates the media from the adventitia during a dissection. A false lumen occurs if blood re-enters the true vessel lumen. The dissection lumen may thrombose and cause stenosis of the true …
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