An 80-year-old woman with a history of left insular infarct experienced sudden loss of consciousness in the setting of persistent atrial fibrillation. She was not treated with long-term anticoagulation therapy. On neurological examination, she had a Glasgow Coma Scale score of 4 with extensor posturing. The patient also exhibited roving ping-pong gaze but had normal brainstem function, including pupillary, corneal, vestibulocochlear, and gag reflexes. The constellation of coma, roving ping-pong gaze, and preserved brainstem reflexes was consistent with bihemispheric structural injury.
1
Computed tomographic angiography (left) showed an abrupt cutoff of the proximal right (white arrow) and left (black arrow) middle cerebral artery (MCA). During right common carotid artery injection (right), the posteroanterior view showed occlusion of the proximal right MCA (white arrow), and injection into the left common carotid artery showed occlusion of the mid left MCA (black arrow). The indistinct borders of the occlusions suggested an intraluminal filling defect in each MCA. The acute bilateral M1 stenosis was most likely embolic in origin. To our knowledge, only bilateral carotid occlusions,1
but not acute bilateral M1 occlusion, and coma associated with atrial fibrillation have been reported previously.Acknowledgments
We thank Drs Jonathan M. Morris and David F. Kallmes, Division of Neuroradiology, Mayo Clinic, for their expert opinions and editorial assistance in the preparation of the submitted manuscript.
REFERENCE
- Sudden coma from acute bilateral internal carotid artery territory infarction.Neurology. 2002; 58: 1846-1849
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© 2007 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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