Case 351

Area of Science:

• Neurology
• Radiology
• Vascular Medicine

Background:

• A 76-year-old male with diabetes, hypertension, and dilated cardiomyopathy presented with subacute onset of confusion, falls, and urinary incontinence.
• Symptoms progressed over 3-4 months, worsening significantly in the 2 weeks prior to presentation, with new memory lapses and functional cognitive deficits.

Purpose of the Study:

• To investigate the cause of rapidly progressive neurological decline in an elderly patient with multiple comorbidities.
• To illustrate the diagnostic challenges and imaging findings associated with rare cerebrovascular pathologies.

Main Methods:

• Initial evaluation included noncontrast head CT, followed by multiphasic CT angiography with parenchymal phase imaging.
• Serial noncontrast CT scans and noncontrast MRI of the brain were performed due to symptom worsening.
• Digital subtraction angiography with selective carotid artery injections was utilized for definitive vascular assessment.

Main Results:

• Initial CT scans were unremarkable for acute intracranial processes, prompting further vascular imaging.
• Despite normal initial laboratory findings and neurological examination, the patient developed seizure episodes and increased drowsiness.
• Advanced imaging, including digital subtraction angiography, was crucial in identifying the underlying cerebrovascular abnormality.

Conclusions:

• This case underscores the importance of considering rare cerebrovascular diseases in the differential diagnosis of acute or subacute neurological deterioration, especially in patients with cardiovascular risk factors.
• Multimodal imaging, progressing from CT to MRI and angiography, is essential for accurate diagnosis and management planning.
• Prompt recognition and diagnosis of such conditions are critical for appropriate therapeutic interventions and patient outcomes.