Attending Physician Harvard PM&R / Spaulding Rehabilitation Hospital Charlestown, Massachusetts, United States
Case Diagnosis: Acute on subacute bilateral pontine strokes with resultant anarthria
Case Description: A 74 year old right-handed man with a history of type 2 diabetes, hyperlipidemia, hypertension and right pontine ischemic stroke with minimal residual deficits presented with right hemiplegia and dysarthria. Imaging revealed a left pontine ischemic stroke. He was transferred to an inpatient rehabilitation facility (IRF) and was functionally progressing until day 10, when he was reported to have developed acute left hemiplegia and aphasia. He was transferred back to acute care where he returned to his baseline speech and strength without intervention. A CT Head was unremarkable and he was started on levetiracetam for seizure prophylaxis. One day later, his symptoms re-occurred and did not resolve with an increased levetiracetam dose at the IRF. A subsequent brain MRI showed a new right pontine stroke.
Discussions: Initially, the rapidly resolving aphasia and left sided weakness in a right handed individual was diagnosed asTodd’s paralysis following an unwitnessed seizure rather than TIA or stroke. In hindsight, the presentation is revealed to be a stuttering right pontine stroke superimposed on a subacute left pontine stroke. While initially characterized as aphasia, the patient’s lack of verbal output was ultimately diagnosedas complete anarthria, as he was able to follow complex commands and reliably answer questions using non-verbal methods of communication. This distinction was relevant not only for his rehabilitation, but also for his acute stroke care as he was able to provide an accurate infectious disease history using non-verbal communication that led to further workup for his rapidly reoccurring pontine strokes and diagnosis and treatment for latent syphilis.
Conclusions:
Conclusions: It is important to clinically distinguish anarthria from aphasia when localizing a neurologic lesion and to consider pontine TIA in the differential for a patient with a history of prior posterior circulation infarcts.
