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Images in Neurology |

Fibrous Cap Enhancement in Symptomatic Atherosclerotic Basilar Artery Stenosis

Mervyn D. I. Vergouwen, MD, PhD; Frank L. Silver, MD; Daniel M. Mandell, MD; David J. Mikulis, MD; Timo Krings, MD, PhD; Richard H. Swartz, MD, PhD
Arch Neurol. 2011;68(5):676. doi:10.1001/archneurol.2011.89.
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A 69-year-old woman with hypertension, non–insulin-dependent diabetes mellitus, and hyperlipidemia had several episodes of visual disturbances, unsteady gait, nausea, and vomiting over several weeks. At presentation, neurological examination revealed bilateral visual field defects and impaired tandem gait. A 3-T magnetic resonance imaging (MRI) brain scan showed acute bilateral cerebellar, occipital, temporal, and right thalamic infarctions (Figure, A). Three-dimensional time-of-flight magnetic resonance angiography demonstrated severe midbasilar artery stenosis (Figure, B). A 3-T high-resolution MRI showed eccentric wall thickening at the stenosis site (Figure, D). After gadolinium was administered, enhancement of the fibrous cap but not the lipid core (Figure, E) was observed. The basilar artery stenosis was managed with a stent (Figure, C). Following a very gentle and undersized predilatation with a Voyager balloon (20 × 1.5 mm; Abbott Vascular, Abbott Laboratories, Abbott Park, Illinois), a Wingspan stent (15 × 3 mm; Boston Scientific, Natick, Massachusetts) was inserted via an exchange guidewire. The patient received maintenance treatment with clopidogrel bisulfate, aspirin, ramipril, and high-dose atorvastatin calcium. In follow-up 6 months later, she was doing well with no new cerebral ischemic events and a modified Rankin Scale score of 1.

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Vessel wall imaging of midbasilar stenosis with fibrous cap enhancement. A, Diffusion-weighted magnetic resonance imaging showed acutely restricted diffusion in both occipital lobes and the right thalamus. B, The 3-dimensional time-of-flight magnetic resonance angiogram showed severe midbasilar stenosis (arrow). C, The poststenting angiogram showed increased luminal diameter in the midbasilar artery. D, Axial T1-weighted fluid-attenuated inversion recovery magnetic resonance imaging without contrast showed eccentric wall thickening (arrow). There is no false lumen or methemoglobin to suggest dissection. E, Postcontrast axial T1-weighted fluid-attenuated inversion recovery magnetic resonance imaging showed eccentric wall enhancement (thick arrow), with an isointense lipid core (thin arrow). F, Enhancement (arrow) was also seen on the postcontrast coronal T1-weighted fluid-attenuated inversion recovery magnetic resonance image.

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