Vertebrobasilar dolichoectasia (VDE) is a rare cerebrovascular disorder characterized by elongation, tortuosity, and vertebral or basilar artery dilation. VDE is associated with ischemia and intracranial hemorrhage. Compared to other causes of subarachnoid hemorrhage (SAH), case fatality due to SAH in VDE is high. We present a case of ischemic stroke in a patient with large VDE, complicated by fatal SAH and obstructive hydrocephalus.

A middle-aged man with hypertension and methamphetamines use presented with right-sided weakness. On initial presentation at an outside hospital, he was found to have right hemiplegia involving the face and body, aphasia, and dysarthria, with a National Institutes of Health Stroke Scale (NIHSS) of 20 but stable vital signs. CT angiogram showed VDE with extensive thrombosis, and he was started on low-intensity heparin drip. Upon transfer to our institution, MRI showed acute infarct in the left pons and cerebellum and large dolichoectasia of the left vertebral and basilar artery measuring up to 17mm. The dolichoectatic vessel also had a fusiform pseudo-aneurysmal dilatation secondary to a dissection, resulting in a mass effect on the brainstem, cerebellum, and the fourth ventricle, with mild hydrocephalus. It also had extensive intraluminal thrombosis. The decision was made to discontinue heparin and initiate aspirin 325mg daily on hospital day 1 due to intracranial dissection. The patient’s symptoms improved to NIHSS of 13. However, the patient was found to be nonresponsive on hospital day 5. CT head showed diffuse SAH with intraventricular extension. The patient progressed to brain death in the following week.