Why did he suddenly de-saturate?

Clinical scenario: 

A 56-year-old male known case of Type 2 Diabetes and hypertension poorly controlled presented with a history of sudden onset gait disturbance and slurred speech of one-day duration. 

Patient  s examination revealed Pulse 76/min regular BP180/120mm of Hg 

CNS: Motor aphasia, positive Babinski's sign, Grade 3/5 Power in both lower limbs 

The detailed neurological examination could not be carried out due to speech disturbance.

CVS: Normal, no murmur or irregular pulse 

Clinical Impression: Cerebrovascular accident 

Hemogram: Normal 

LFT/RENAL FUNCTIONS: Normal

ECG: Normal sinus rhythm 

ECHO: Normal

Fig1 CT scan showing hypodense area in Cerebellar area 

The CT scan showed hypodense zones in Cerebellum as above

Fig2 Diffusion MRI suggestive of Acute stroke 

 The diffusion MRI is shown in Fig2 Suggestive of Acute stroke

Fig 3 MR Angio:  Absence of  Right Inferior vertebral artery? thrombosed?? absent  

Day 2 patient suddenly developed desaturation.

• He  was intubated 
• MRAngio shows occluded vertebral  artery and its branch PICA ( shown by the arrow in Fig3)
• Affecting the Medullary region leading to the respiratory center involvement explaining sudden desaturation 

Final Diagnosis: Acute Left PICA territory infarction 

• Management: Patient was initially managed in ICU and later shifted to the ward and is improving 

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This case was contributed by 

Dr.  Yahea Alzahrani

Consultant Neuro Radiologist 
Assistant Professor 
College of Medicine Taif University 

Taif Saudi Arabia