Abstract
Abstract A man in his 60’s complained of vertigo and ‘vision tilt’ following a dental procedure. A cerebellar haemorrhage and cerebral microbleeds (CMBs) were diagnosed on imaging. Subsequent testing revealed CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). The role of the dental procedure as a trigger for intracerebral haemorrhage (ICH) is discussed.
Case A male in his 60s presented to emergency department after having two teeth extracted under local anaesthetics. Thirty minutes after the procedure he had a sudden onset of nausea, vomiting, dizziness, and visual changes such as rotation of objects 90 degrees anticlockwise direction.
On examination, there was left-sided nystagmus at extreme gaze. The gait was unsteady with the patient falling to the right side. There was mild incoordination of the left upper limb.
Urgent CT of the brain showed a left cerebellar haemorrhage adjacent to the 4th ventricle extending up to the wall of the ventricle. Further magnetic resonance imaging (MRI) of the brain showed a focal ovoid hematoma in the region of the left dentate nucleus with extensive punctate haemosiderin foci, predominantly involving the thalami, but also the pons and contralateral cerebellum as well as a few more peripherally located foci within the fronto, parieto and temporal cortices. Severe confluent periventricular and mild pontine leukoencephalopathy were also noted which likely represents small vessel ischemic changes. Genetic analysis was consistent with CADASIL diagnosis.
