To describe a case of vertebrobasilar dolichoectasia (VBD) complicated with acute obstructive hydrocephalus and ischemic stroke

VBD is a rare anatomical variation characterized by elongation and tortuosity of vertebrobasilar artery. Rarely, it can be complicated with ischemic stroke and obstructive hydrocephalus.

Case report

A 64-year-old man with hypertension presented with progressive confusion for 1 day. Initial neurological examination showed lethargic with no overt focal deficit. Labs showed no leukocytosis or significant metabolic derangement. Urine drug screen was negative. Initial Non-contrast CT and CT angiogram of the head showed dilation of all ventricle and calcified dolichoectatic basilar artery. MRI brain demonstrated acute infarction in the posterior body and splenium of the corpus callosum. Electroencephalogram showed generalized delta activity without epileptiform discharge. Patient’s neurological status declined rapidly after admission and required intubation. Follow up CT head at 24 hours after hospitalization showed progressive enlargement of ventricles. The progression of the enlargement of the lateral and third ventricles were out of proportion the fourth ventricle. Therefore, obstructive hydrocephalus was diagnosed and urgent external ventricular drain (EVD) was placed. Open pressure was 50 cm H2O. After EVD placement, the patient was significantly improved. Repeated CT head after EVD confirmed improvement of effacement of the cerebral sulci and hydrocephalus. Ventriculoperitoneal (VP) shunt was placed prior to discharge. Telemetry did not capture any cardiac arrhythmia. Transthoracic echocardiogram was normal. The patient was started on aspirin and atorvastatin for secondary stroke prevention

Acute obstructive hydrocephalus and ischemic stroke are the rare complications of VBD. The diagnosis is clinically urgent and easily overlooked. Our case demonstrated a favorable outcome after urgent EVD and VP shunt in obstructive hydrocephalus secondary to VBD.  There is no consensus for the management of stroke caused by basilar dolichoestasia.