1549 - Persisting lightheadedness after a mild traumatic brain injury due to cerebral hypoperfusion

Case Diagnosis: 70-year-old woman presented with persisting intermittent lightheadedness ten months after sustaining a mild traumatic brain injury (mTBI) from a ground-level fall.

Case Description: Symptoms included headache with vision changes, dizziness, imbalance, fatigue, neck pain, and left-hand clumsiness, which all began after mTBI. Exam was without focal deficit. Patient trialed vestibular therapy with modest improvement in dizziness. Frequent headaches, lightheadedness, hand clumsiness, and neck pain continued without identifiable triggers. MRI C-spine revealed central and neuroforaminal narrowing. EMG showed bilateral cubital tunnel syndrome. Oral medications were trialed, including Pregabalin, muscle relaxants, and steroids without symptom alleviation. C7-T1 interlaminal epidural steroid injection alleviated paresthesias, but intermittent left grip weakness persisted. A difficult cardiac catheterization prompted further vascular work-up. Imaging demonstrated severe innominate artery stenosis, right vertebral artery retrograde flow, bidirectional flow in right common and external carotid arteries, near occlusion of left subclavian and right vertebral arteries, and brachiocephalic artery occlusion. Patient underwent left subclavian artery stenting and left to right axillary artery bypass, resulting in complete resolution of headache, dizziness, cramping, and upper extremity numbness.

Discussions: Persisting symptoms after mTBI vary widely among patients, making treatment and guidance through an individual patient’s recovery clinically challenging. Poor outcomes are frequently related to comorbid or premorbid conditions. Maintaining a large differential when treating suspected refractory symptoms can avoid missed diagnoses.

Conclusions: In patients with vascular comorbidities whose persisting symptoms after mTBI do not improve over the expected duration, further investigation into vascular etiologies is reasonable.