Dr. Yiping Li Spokane Neurosurgery

Young man presents with sudden paralysis of the left arm and leg, facial droop, double vision with difficulty moving his eyes, and difficulty speaking. He was evaluated in the ER and found to have acute bleeding within the brainstem in the pons.

Initially he was diagnosed with a hemorrhagic stroke and thought to be due to high blood pressure; however, follow up imaging a week later showed continued enlargement of the bleed.

Due to the patient's age, I suspected that there was an underlying blood vessel mass called a cavernous malformation, which is like a hemorrhoid of the brain / tangle of fine blood vessels that can become engorged and cause local bleeding and damage.

The patient underwent urgent surgical resection of the mass due to progressive bleeding. The patient tolerated the procedure well. Post operatively he started to regain the movement in his arm and leg and by 6 weeks follow up he was walking without assistance and was able to hold a fork and eat with his left arm. He still had some double vision but this was also improving. Imaging shows a brainstem pontine cavernoma before and after surgical resection.

Sometimes large aneurysms can cause compression of cranial nerves. In this case a young person presents with progressive vision loss. She was found to have a large aneurysm compressing the nerve to her eye.

Although flow diversion (stenting) has revolutionized the treatment of these aneurysms, sometimes to get the pressure off the nerves quickly, surgery is still superior.

Here are some images of the aneurysm before and after surgery where blood to the aneurysm was stopped, the aneurysm was deflated, and a simple clipping was performed to relieve pressure onto the nerve of the eye.