Identification of the precise cause is fundamental to the secondary prevention of acute ischemic stroke. Several uncommon causes of stroke have been identified as a result of the attempts made to identify the cause of a cryptogenic stroke. However, unless proper protocol is followed each time, without missing any steps, it might not be possible to accurately determine the cause of strokes. Herein, we report a case wherein the cause of stroke was not detected in time because a fundamental step was missed while attempting to determine the cause. The 44-year-old male patient in our case developed recurrent ischemic stroke due to vertebral artery dissection. Although vertebral artery dissection is not a rare cause of stroke, it was missed while focusing on the rare embolic condition, Valsalva sinus aneurysm. Although a cardiac embolism is a potential cause of stroke in the present case, it is critical to examine all parts from the ostium to the end of the relevant artery (vertebral arteries) when checking for the possible causes of stroke. The ideal protocol to be followed when determining stroke etiology would be as follows: 1) identifying anatomical location and vascular territory of the lesion, 2) evaluating relevant arterial pathology or testing potential embolic source according to the presence of one relevant artery for ischemic lesion, and 3) performing a detailed evaluation of the rare causes of stroke.
Keywords: Arterial topography; cerebral infarction; diagnostic testing; etiology; ischemic stroke; vascular imaging.