Avoiding pitfalls in diagnosing basilar artery occlusive disease: clinical and imaging clues - case report.
BACKGROUND
The aim of this paper was to report on the characteristics that aid in establishing the diagnosis of basilar artery occlusive disease (BAOD) among patients with hemiparesis and few or minor symptoms of vertebrobasilar disease.


METHODS
This report describes two cases in a public university hospital in São Paulo, Brazil. We present clinical and imaging findings from two patients with hemiparesis and severe BAOD, but without clinically relevant carotid artery disease (CAD). One patient presented transient ischemic attacks consisting of spells of right hemiparesis that became progressively more frequent, up to twice a week. The neurological examination revealed slight right hemiparesis and right homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed pontine and occipital infarcts. Magnetic resonance angiography and digital subtraction angiography revealed severe basilar artery stenosis. The other patient presented sudden left-side hemiparesis and hypoesthesia. One year earlier, she had reported sudden onset of vertigo that, at that time, was attributed to peripheral vestibulopathy and was not further investigated. MRI showed a right-side pontine infarct and an old infarct in the right cerebellar hemisphere. Basilar artery occlusion was diagnosed. Both patients presented their symptoms while receiving aspirin, and became asymptomatic after treatment with warfarin.


CONCLUSIONS
Misdiagnosing asymptomatic CAD as the cause of symptoms in BAOD can have disastrous consequences, such as unnecessary carotid endarterectomy and exposure to this surgical risk while failing to offer the best available treatment for BAOD. Clinical and imaging features provided important clues for diagnosis in the cases presented.
Hospital das Clínicas (HC), Universidade de São Paulo (USP), São Paulo, Brazil. abconf@yahoo.com
Adriana Bastos
AB
Conforto
Jovana Gobbi Marchesi
JG
Ciríaco
Fábio Iuji
FI
Yamamoto
Paulo
P
Puglia Júnior
Claudia da Costa
Cda C
Leite
Maria da Graça Morais
Mda G
Martin
Milberto
M
Scaff
D000368:Aged; D001157:Arterial Occlusive Diseases / Q000175:diagnosis*; D001488:Basilar Artery; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000503:physiopathology; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000175:diagnosis*; D014715:Vertebrobasilar Insufficiency / Q000175:diagnosis*