History
Mr. So, a 70-year-old chronic smoker, presented sequential limb weakness of hyperacute onset:
- Left hand weakness.
- Dense right hemiplegia and dysarthria .
- Left lower limb weakness.
- Non-progressive symptoms with interval partial recovery .
- In the setting of cystitis / prostate abscess complicated with septic shock, AKI, ARDS, and Waterhouse-Friderichsen syndrome.
Initial neurology impression for the left hand weakness: left AIN palsy; orthopedic impression: proximal left median nerve palsy.
Neurology team was therefore reconsulted to reconcile the clinical presentation after the acute phase.
Physical examination
Alert and oriented, right UMN facial weakness, bilateral asymmetrical pyramidal weakness.
No signs suggestive of a cord syndrome.
Investigations
CTB: evolving infarct at the right posterior watershed and left pontine region.
Blood culture negative; inflammatory markers normalized.
Cardioembolic workup unremarkable.
Thought process
Syndrome: sequential hyperacute focal neurological deficits with above-neck symptoms and signs; disease trough at onset with interval recovery.
Localization: cerebral (right posterior watershed and left pontine region).
Etiology: vascular (multi-territory arterial ischemic stroke / perfusion infarct due to severe systemic hypotension.
- DDx: concomitant large vessel disease, embolic (esp. septic embolism).
Learning point: the key to this diagnosis lay in the clear delineation of the time course of each neurological symptom.
Outcome
Brain MRI: acute infarct at right posterior watershed and left pontine region; no significant large vessel disease.