Case Description
A 65-year-old woman with hypertension, hyperlipidemia, ascending aortic aneurysm repair and valve replacement, and periprocedural atrial fibrillation (not on anticoagulation) presented with sudden-onset imbalance. The patient was on a treadmill when she experienced acute gait instability without vertigo. She held onto the bars to stay midline; otherwise, she leaned rightward. Examination revealed past-pointing and ataxic gait without dysarthria or nystagmus. Brain MRI demonstrated small superior vermis infarct. MRA revealed no significant stenosis. CTA of the chest showed an increase in known aortic pseudoaneurysm (Figure). Such pseudoaneurysms are not known to form thrombi or become embolic sources; she continued aspirin without anticoagulation. Gait instability and vertigo are common presenting signs of cerebellar infarction1; isolated lateropulsion may be seen in lesions involving the vermis.2
Axial brain MRI demonstrates diffusion restriction (A) with apparent diffusion coefficient correlate (B) in the right superior vermis (arrows), consistent with acute ischemic infarct. Chest CT angiography (C) reveals a 12 × 7 mm contrast outpouching (arrow) arising from the lateral wall of the aorta at the proximal graft anastomosis, consistent with pseudoaneurysm. Ao = ascending aorta; Pv = pulmonary vein.
Study Funding
The authors report no targeted funding.
Disclosure
The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.
Acknowledgment
We thank the patient for providing consent for us to share this case for teaching purposes.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures.
Submitted and externally peer reviewed. The handling editor was Roy Strowd III, MD, Med, MS.
Teaching slides links.lww.com/WNL/C470
- Received April 26, 2022.
- Accepted in final form September 27, 2022.
- © 2022 American Academy of Neurology
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