Teaching NeuroImage: Vertebrobasilar Dolichoectasia Presenting as Spastic Paraparesis

A 65-year-old man with a history of hypertension presented with 10 years of progressive spastic paraparesis. Examination revealed brisk reflexes in the lower limbs and extensor plantar responses. MRI of the spinal cord showed mild dorsal cord atrophy. MRI of the brain showed vertebrobasilar dolichoectasia (VBD) compressing the medulla (Figure 1). Tractography confirmed Wallerian degeneration of the bilateral pyramidal tracts distal to the pontomedullary junction (Figure 2). VBD constitutes elongation, enlargement, and tortuosity of vertebral and basilar arteries. Symptoms arise due to either compression or ischemia.1 Medullary compression causes weakness, cranial neuropathies, and cerebellar ataxia. Surgical and endovascular repair are the currently available therapies.2