1557 - Unusual presentation of right-sided neglect after right MCA stroke: A case report

Case Diagnosis: Right MCA infarction status post decompressive hemicraniectomy

Case Description: A 61-year-old male with history of hypertension and hyperlipidemia initially presented with left sensorimotor deficits and right gaze preference, found with acute infarct of the right MCA with hemorrhagic conversion, resulting in mass effect and 5mm evolving to 10mm leftward midline shift, now status post right decompressive hemicraniectomy. He was ultimately transferred to an inpatient rehabilitation hospital where he presented with right-sided neglect on admission.

Discussions: Left-sided neglect typically results from damage to the right cerebral hemisphere after a right MCA stroke. Neglect in acute stroke is an important predictor of poor functional recovery. Literature suggests that neglect may negatively impact rehabilitation outcomes more than hemiplegia, making recognition of neglect essential. This patient demonstrates an unusual presentation of right-sided neglect following a right MCA stroke. Imaging demonstrated a right basal ganglia intraparenchymal hemorrhage and mass effect with a 5mm left midline shift with interval expansion to 10mm on repeat. Midline shift can cause secondary brain injury from compression of the contralateral hemisphere, which may be the mechanism behind this patient’s presentation. Although he underwent decompressive hemicraniectomy, postoperative MRI demonstrated a 4mm left midline shift, suggesting residual compression of the left hemisphere that may have resulted from post-stroke cerebral edema.

Conclusions: This patient's stroke deficits included left-sided weakness, left-sided neuropathic pain, and right-sided neglect. His significant left spatial preference resulted in neck pain and stiffness, limiting his range of motion and impacting his therapy. Therapy goals included improving attention to midline and right-sided environment. This case highlights an unusual presentation of right-sided neglect in a patient with a right MCA stroke and left midline shift. Although rare, damage to the left side of the brain can cause right-sided neglect. This emphasizes the importance of recognizing this nonclassical presentation with the goal of improving stroke rehabilitation outcomes.