Diagnosis and Management of Active Intracranial Atherosclerotic Disease: A Case Study.

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A 68-year-old man with a past medical history of hypertension and hyperlipidemia was admitted with dizziness and right-sided weakness. Neurological examination revealed mild right hemiparesis but was otherwise normal. The initial brain magnetic resonance imaging (MRI) was negative for any acute abnormalities; magnetic resonance angiography showed irregularity of the right intracranial vertebral artery with mild stenosis (Figure 1A). A follow-up brain MRI confirmed a left pyramidal stroke. He was discharged to an inpatient rehabilitation facility on aspirin and high-intensity statin therapy. Figure 1. A , Magnetic resonance angiography of the head showing atherosclerotic changes in both vertebral arteries more prominent on the right (blue arrow). B , Diffusion-weighted imaging sequence showing an acute left cerebellar infarct (blue arrow). C , Magnetic resonance angiography of the head showing worsening atherosclerotic disease in right vertebral artery (blue arrow) and occlusion of the left vertebral artery (black arrow). D , Diffusion-weighted imaging sequence showing an acute left cerebellar infarct and a right occipital infarct (blue arrow). One year later, he was admitted for transient visual distortion and dizziness which lasted 15 minutes. Neurological examination noted mild right hemiparesis with no other new findings. MRI brain revealed a small acute left cerebellar infarct (Figure 1B) and magnetic resonance angiography of the head and neck demonstrated worsening atherosclerosis in the right intracranial vertebral artery with severe stenosis and interval occlusion of the left intracranial vertebral artery (Figure 1C). Aspirin was switched to clopidogrel monotherapy and statin therapy was maintained. Two days after discharge, he was readmitted for transient dizziness and imbalance lasting 30 minutes. His examination had returned to baseline on hospital arrival. Repeat MRI of the brain showed new small acute bilateral cerebellar infarcts and a punctate right occipital acute infarct (Figure 1D). Magnetic resonance angiography of the …