A 51-year-old male experienced over a period of 6 months a major stroke and several transient ischemic attacks (TIAs) of vertebrobasilar distribution. The original episode consisted of loss of balance, loss of coordination, and loss of the left visual field while driving a bus, which resulted in a road accident. Since then, he had experienced four additional episodes of aphasia and paraparesis lasting for 4-5 h. A diagnosis of vertebral artery dissection was made at the local hospital and he was placed on Coumadin. Concomitant diagnoses were hypertension, non-insulin-dependent diabetes, and hypercholesterolemia. In spite of adequate international normalized ratio (INR) levels, his symptoms continued and he was referred to us.
On admission, magnetic resonance imaging (MRI) showed right occipital and left cerebellar infarctions (Fig. 31.1).
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