ABSTRACT BODY: This is a case of a man who presented with high frequency of falling and worsening gait unsteadiness over past one month with violent hiccups and cough secondary to fusiform aneurism of basilar artery compressing the cervical medullary junction. A 71-year-old left hand dominant male with history of hypertension, hyperlipidemia, status postus left herniorrhapy, a few months of hiccups and coughs, who experienced sudden fall without loss of consciousness, and with ataxic gait three weeks prior to presentation. Work-up including CT head scan, echocardiogram, lower extremity doppler study, and cerebral angiogram were negative. However, MRI brain demonstrated fusiform aneurysm of basilar artery compressing the cervical medullary junction of brainstem and multiple punctuate infarcts in anterior circulation. He denied nausea, vomiting, lightheadedness, diplopia, and headache, neurologic deficits, dysphagia, and dysarthria. Conservative management was recommended as per neurosurgery.
SETTING: Tertiary care hospital (academic rehabilitation facility)
Clinical course: During his acute rehabilitation, he experienced spontaneous intractable bouts of hiccups and violent coughs. Antianxiety medication, Sertraline was titrated from 25mg to 100mg for his overacting behavior and new onset impulsiveness with good effect. Regarding his hiccups, Baclofen was not successful, but Chloropromazine did relieve his symptoms. On admission 2-minute-timed test was 120 feet, 6-minute-walk-test was 120 feet and total FIM score was 34. On discharge 2-minute-timed test was 95 feet, 6-minute-walk-test 300 feet and total FIM score was 75.
DISCUSSION: An aneurism of basilar artery is seen in 5 % of cases from all aneurysms of the Circle of Willis. This aneurysm can be ruptured, or occluded by a thrombus. Our case showed no sign of rupture or thrombus occlusion in basilar artery other than compression of the cervical medullary junction. Ataxia and impulsiveness were improved through antianxiety medication and multidisciplinary acute rehabilitation therapies. Patient was recommended to follow up with a neurosurgeon monthly for any changes.
CONCLUSION: A fusiform basilar artery can cause thrombosis or rupture. Considering the efficacy and limitation of interventional procedures like intravascular stenting, conservative monitoring is recommendable in this case.
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