A 30-year-old man with an unremarkable medical history was admitted to the emergency room after experiencing numbness on the right side of his face and dizziness while playing basketball. He recounts that he quickly had a transient cold sensation on the right side of his face extending to his right arm and leg. These symptoms were followed by a cramp-like sensation on the right arm and weakness of the right leg. Afterward, the remaining symptoms were weakness/numbness on the right side of the face and difficulty with speech and swallowing. The patient recently had an uneventful upper respiratory tract infection and had no toxic habits. Family history was unremarkable.
In the emergency room, he had right facial asymmetry with tongue deviation to the right and right hemiparesis. Laboratory values and the initial head computed tomography scan were unremarkable. Forty-eight hours later, magnetic resonance imaging (MRI) of the brain showed multiple recent infarcts at both cerebellar hemispheres, suggestive of a VAD (Figure 1). Magnetic resonance angiography (MRA) showed bilateral VAD (Figure 2). He was anticoagulated and required gastrostomy for severe dysphagia.
The patient was admitted to an inpatient rehabilitation facility where he scored 81 on the Functional Independence Measure at initial evaluation. He was discharged after 16 days, with a score of 107. At 6 months, he was asymptomatic, and continues to work as a security guard.