Journal of Clinical Neuroscience (2005) 12(1), 47–48 0967-5868/$ - see front matter ª 2004 Published by Elsevier Ltd. doi:10.1016/j.jocn.2004.09.002 Images in neuroscience Images in neuroscience Janaka Seneviratne MBBS, Mervyn Ferdinands MBBS Department of Neurology, The Royal Melbourne Hospital, Parkville, Australia A 44-year-old male presented with transient episodes of sudden onset dysarthria, vertical diplopia and quadriparesis lasting 1–2 min. These symptoms started one week prior to hospital admission and occurred daily. There was no other past medical history and he was not on regular medication. On examination, BP was 120/ 80, pulse 80, sinus rhythm and there were no focal neurological deficits. Routine blood tests and CT brain scan were normal. T2-weighted MRI (Fig. 1), DWI imaging (Fig. 2) and cerebral angiogram films (Figs. 3 and 4) are shown. WHAT IS THE MOST LIKELY DIAGNOSIS? 1. Demyelinating disorder 2. Cerebral vasculitis 3. Vertebral artery dissection 4. Seizures secondary to encephalitis 5. Brain stem glioma Fig. 3. Lateral vertebral angiogram. Fig. 1. T2-weighted axial MRI. Fig. 2. DWI axial MRI. Fig. 4. AP vertebral angiogram. 47 48 Seneviratne and Ferdinands ANSWER: (3) VERTEBRAL ARTERY DISSECTION On further questioning, the patient stated that he was performing neck exercises for neck stiffness when the first symptoms occurred. His first symptom was sharp neck pain, followed by the transient neurological episode. Vertebral artery dissection was suspected clinically and he was commenced on heparin infusion. His presenting symptoms preceeded by neck exercises have been described with spontaneous vertebral artery dissection.1 The MRI images are consistent with bilateral acute pontine infarcts. The cerebral angiogram shows bilateral vertebral artery Journal of Clinical Neuroscience (2005) 12(1), 47–48 dissections. He did not experience any further symptoms on heparin infusion, and was discharged on warfarin therapy for 3 months. The optimal treatment for cervical artery dissection is uncertain, although anticoagulation is widely used.2 REFERENCES 1. Schievink WI. Current concepts: spontaneous dissection of carotid and vertebral arteries. NEJM 2001; 344: 898–906. 2. Hankey GJ, Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Stroke 2004; 35: 613–614. ª 2004 Published by Elsevier Ltd.