To present a case on recurrent posterior circulation strokes induced by sneezing in a patient with pseudoaneurysm adjacent to vertebral artery take-off.

Sneezing, a normal physiological response, can lead to increased intrathoracic pressure, which may cause vascular consequences in predisposed individuals. Stroke is a documented albeit rare result from sneezing, typically due to dissection.

Herein, we present a case of a 49-year-old male with history of aortic arch surgery due to congenital aberrations who presented with sudden nausea, vomiting, headache, and confusion following a paroxysm of sneezing. MRI revealed acute infarcts in bilateral posterior circulation consistent with embolic shower. CTA demonstrated the surgical repair of congenitally aberrant aorta. Stroke workup was otherwise unrevealing, so patient was diagnosed with embolic stroke of undetermined source (ESUS). Outpatient cardiac event monitor was similarly negative. 2-3 months later, patient presented with similar symptoms following a paroxysm of sneezing. MRI demonstrated new areas of left cerebellar infarction, and stroke workup was again unremarkable. He was discharged on lovenox and aspirin and given an implantable loop recorder, which was unrevealing. After 11 quiescent months, patient presented again with same presentation as above, with sneezing induced symptoms, MRI confirming acute medial right cerebellar stroke. Reanalysis of his previous CTA revealed a difficult to recognize and previously missed pseudoaneurysm next to his right vertebral artery take-off. Patient had corrective aortic surgery and has since remained sneezing stroke free.

This case highlights a highly unique clinic case of recurrent sneezing-induced strokes. Sneezing-induced amplified intrathoracic pressure could cause susceptible emboli to break off, leading to strokes. The specific etiology here is, however, highly rare. This case also highlights the importance of re-evaluating the subtleties of imaging abnormalities when suspicious for pathology.