Basilar & Vertebral Artery Stenosis

[bm06789]

Complete history in relation to neurology is provided below. The patient has had multiple CTA, MRA, MRI and CT scans over the past 20 years.

(1) What is the chance of a stroke? When is the next stroke likely?
(2) Do you see any other neurological issues (i.e., intracranial hypertension due to empty sella)?
(3) Please help based on the information provided. I can give you MRI images if need be.


BRAIN (MRI & CT)
• Vertebrobasilar Insufficiency.
• Brain Stem Stroke Syndrome, in 2000.
• Left parietal Subdural Hematoma 30mm thick (SDH evacuation, in 1998) + 15mm midline displacement, due to brain trauma in 1998.
• MRI Brain: Bilateral deep white matter ischaemia; ventricles and surface CSF spaces are enlarged; an empty sella; Multiple focal bilateral subcortical and periventricular white matter lesions; scattered foci; widening of the cortical sulci, lipohyanlianosis; moderate microvascular ischaemic disease; vermian atrophy in posterior fossa; pituitary gland is atrophic; cerebellar tonsils are above the level of the foramen magnum.
• Rotatory Vertigo, Chronic Dizziness, Fatigue and Headache.
• Mild Dementia.
• Abnormal right leg & numbness, radiating dull ache pain, facial numbness, writing tremor.

NECK VESSELS (MRA & CTA):
• Basilar Artery: 50% stenosis (distal) and reduced flow.
• Left Vertebral Artery: occluded at distal V3.
• Right Vertebral Artery: 50% - 70% stenosis at V4.
• Middle & Anterior Cerebral Artery: mildly irregular opacification.
• Carotid siphons and carotid bulbs: atherosclerotic plaque.
• Cervical spine: lordosis straightening, low grade disc bulge, root compression.

SPINE (MRI):
• L4-L5:  broad-based posterior disc bulge, bilateral facet joint arthropathy and thickening of the ligamentum flavum results in moderate to severe narrowing of the spinal canal.
• C5/6: moderate spinal canal narrowing.
• T10/11 and T11/12: facet joint osteo-arthropathy with indentation of the thecal sac posteriorly.
• Dexamethasone injection in L3/4 on 18-Sep-18. Previously peri-radicular injections since 2010.

OTHERS:
• Ischaemic heart disease (6+ stents).
• Autoimmune disorders (ANA – Nucleolar Pattern).
• Chorionic iron deficiency & anaemia
• Refractory Hypertension.
• Type 2 Diabetes, Hypoglycaemia.
• High Cholesterol, Dyslipidemia
• MEDICATIONS (some): CLOPIDOGREL;  ASPIRIN, ISOSORBIDE MONONITRATE, LABETALOL HYDROCHLORIDE