Postural instability after acute ischemic stroke

Abstract

A 63-year-old man attended the emergency department 6 hours after sudden onset of severe right hemiparesis and dysarthria. He had no significant medical history and presented no known cardiovascular risk factors apart from chronic alcohol abuse. He also had no medication history. Blood pressure was 170/94 mmHg, pulse was regular at 75 beats per minute, and heart sounds were normal. There were no cervical or femoral bruits, and no signs of heart failure. On neurological examination, the patient was alert with right lower facial paresis and dysarthria. Motor examination revealed diminished tone in his right arm and leg. Sensory and visual examinations were normal. His National Institutes of Health Stroke Scale (NIHSS) score was 11/42. Initial laboratory work-up (including complete blood count, electrolytes, blood glucose, and renal function), chest radiograph, and electrocardiogram were normal. A head CT scan did not reveal any early signs of cerebral ischemia. Brain MRI was performed 9 hours after symptom onset and showed a limited acute infarct in the posterior part of the left centrum ovale (Fig. 1A). Magnetic resonance angiography was normal. Carotid ultrasonography and transthoracic echocardiography were normal. Transesophageal echocardiography was not performed. Twenty-four hours after admission to our stroke unit, when sitting or standing, the patient was observed to abduct and extend his non-paretic limbs in order to actively thrust towards his paretic side and resisted all attempts to passively correct his body posture (Fig. 1B, Supp. Video 1). As the patient presented severe motor weakness on the right side associated with postural instability, he was transferred to a rehabilitation center on aspirin (300 mg/ day), atorvastatin (40 mg/day), angiotensin-converting-enzyme inhibitor (perindopril, 5 mg/day), and non-thiazide diuretic (indapamide, 1.5 mg/day). Following intensive physiotherapy, the patient was discharged 90 days after admission with a favorable outcome (NIHSS score 3/42). No new symptoms appeared during 6 months of outpatient follow-up.