Anomalous cerebral vasculature causing acute bilateral anterior circulation storke - a case report

Introduction: Anterior Circulation Stroke is uncommon and accounts for 0.3- 4.4 % of cerebral infarctions. Reports with bilateral infarcts in the anterior cerebral artery (ACA) territory are even rarer¹. 80 % of patients have some degree of asymmetry of the ACA, however variants such as aplasia or hypoplasia of A1/A2 segments are seldom (2-3 %)². In these cases the contralateral A1 segment is hyperplastic and blood is supplied via the anterior communicating artery. The e-poster will present the case of a 64 years old female with severely disabling, bilateral frontal ischaemic strokes due to a variant in the anterior circulation. Both ACA territories were supplied by a single A2 segment. Blockage of this A2 thus caused bilateral ACA infarcts. Objective: To demonstrate this variant in the anterior circulation and it”s resulting consequences through CT and MRI images and to conduct a pictorial review of ACA anomalies. Patients and methods: A 64 years old female was admitted after being found collapsed on the floor. She was last seen well 12 hours before. Her medical history included type II diabetes mellitus and hypertension. Glasgow coma scale was 12/15 (E3 V4 M5), blood pressure 226/150, heart rate 92 beats/minute, regular. Random glucose was 9.0. Pupils were equal and reactive. The patient was aphasic, quadri-plegic and had generalised hypertonia, brisk reflexes and bilateral up-going planters. National Institute of Health Stroke Scale was 25. Rest of the systemic examination was normal. The head CT showed patchy low density in the white matter in keeping with small vessel disease but also raised a suspicion of multiple new infarcts in both the middle and anterior cerebral artery territories. The MRI confirmed multi foci of restricted diffusion scattered throughout the cerebral hemispheres and large, bilateral infarcts involving the parasagittal frontoparietal lobes. The CT angiogram showed the occluded left A2 segment (pericallosal artery prior to paracentral artery) with dom - inance of left A1 and atrophic right A1. Results: The patient was medically stabilised but made a very poor functional recovery with a modified Rankin Score of 5 at discharge. The aetiology is presumed to be cardio-emoblic. Conclusion: Bilateral frontal lobe strokes can be caused by variants in the anterior cerebral arteries. Strokes were already established at the time of presentation, thus thrombolysis or thrombectomy were not performed. This case demonstrates the importance of correlation of vascular anatomy with stroke distribution patterns. References: 1. Menezes B, Cheserem B, Kandasamy J, O Brien D, Acute bilateral anterior circulation stroke due to anomalous cerebral vasculature: a case report. Journal of medical case reports 2008, 2:188. 2. Makowicz G, Poniatowska R, Lusawa M, : Variants of cerebral arteries- anterior circulation. Pol J radiol 2013, 78(3):42-47.