Title : Importance of Blood Pressure Augmentation in Pontine Warning Syndrome, A Stuttering Lacune Presenting as AICA syndrome
A 43 years old male patient with a past medical history of hypertension and hyperlipidemia but noncompliant with medications presented to the hospital after his coworkers noticed a left sided facial droop. He also reports a transient episode of dizziness in the same morning. In ED, physical exam showed left sided upper and lower facial weakness, left sided abducens nerve palsy, left sided diminished facial sensation, left upper extremity subtle ataxia and bilateral hearing impairment. NIH stroke scale score was 4. He denied hyperacusis. Social History was positive for smoking and vaping. Blood pressure was elevated at 180/123. EKG showed sinus rhythm. Labs were remarkable only for hypokalemia at 3,5 with mild elevation of AST and ALT. CT head without contrast ruled out intracranial hemorrhage. Neurology was consulted at bedside and MRI brain without contrast, MRA head and MRA neck were pursued. All imaging tests were unremarkable. There was high suspicion for a stuttering AICA syndrome and the decision was to proceed with permissive hypertension less than 220 and challenge with IV fluid bolus and continue on maintenance IV fluid at 100 ml/hour overnight. He was also loaded with aspirin and clopidogrel. He also started on statin. Physical examination in the next morning revealed resolution of facial palsy, trigeminal nerve palsy and hearing impairment with only persistence of abducens nerve palsy that was improving. Transthoracic echo ruled out cardiac embolism. Blood pressure was persistently above 180 and lisinopril of 5 mg was started. Inflammatory causes of cranial polyneuropathies were ruled out by contrast enhanced MRI. Improvement of systolic pressure to 110 on the third day of hospitalization was associated with new dysarthria 6th International Conference on Neurology and Brain Disorders | October 24-26, 2022 and facial palsy and recurrence of other initial neurological deficits. Challenging with 1 liter of IV fluid, discontinuation of antihypertensive medication and flat bed position resulted in resolution of the deficits. The patient was discharged home on the fifth day of hospitalization.
What will audience learn from your presentation?
Occlusion of AICA is rare and results in a lateral pontine syndrome (AICA syndrome). The symptoms include sudden onset of vertigo, nystagmus, dysarthria, hearing loss, tinnitus and a variety of ipsilateral features (hemiataxia, loss of sensation of the face etc). Cases are often misdiagnosed as TIA Some of these pontine infarcts present with stuttering symptoms, referred to as pontine warning syndrome (PWS) Aggressive BP control and hypotension lead to progression or recurrence of symptoms in PWS and should avoided