Bilateral cerebellar stroke presenting with acute dysphonia and late palatal tremor

Abstract

A 74-year-old woman presented with acute dysphonia and ataxia. Her husband reported that she had been asymptomatic with no speech abnormality immediately prior to the event. She had no significant past medical history nor prior exposure to neuroleptic medications. There was no family history of dystonia. She had been a lifelong and accomplished choir singer, practicing daily for at least an hour. Fast atrial fibrillation was noted during her initial assessment, requiring diuresis for pulmonary congestion and metoprolol for rate control. Speech was mostly incomprehensible with a strained-strangled quality, slow rate, occasional voice arrests, and inappropriate pauses. Of note, phonation in the context of laughter was relatively preserved. The clinical impression was of a spasmodic dysphonia (SD) with additional features of an ataxic dysarthria. Examination of the tongue and palate was initially unremarkable. Tone, power, and reflexes were normal throughout. There was mild appendicular intention tremor with dysmetria but severe truncal ataxia causing retropulsion, even when seated.