Basilar dolichoectasia

This 59-year-old male had hypertension, diabetes, and dyslipidemia and a history of coronary disease treated with coronary bypass grafting as well as abdominal aortic aneurysm repair. He presented with recurrent posterior circulation ischemic events, improving with intravenous tissue plasminogen activator on one occasion and intravenous heparin therapy on the second and third occasions. He was left with infarction in the territory of the left posterior cerebral artery, with right hemianopsia, and verbal memory deficits. CT scanning of brain revealed an ectatic basilar artery with mural calcifications (A). CT angiography demonstrated basilar artery dolichoectasia (B). He was treated with warfarin and remained stable for 3 years. He then presented with dysarthria, ataxia, and facial droop; MRI scan demonstrated an area of restricted diffusion in the right paramedian pons (C), and CT angiogram showed stable basilar artery ectasia with possible mural thrombus formation (D). (Contributed by Dr. J Brorson.)