Title : Generalized tremulousness and stuttering speech: An atypical sequelae of a pontine stroke (case report)
Abstract:
Background: Pontine strokes present a unique set of challenges in diagnosis and management as the clinical presentation can vary significantly. Along with the classic symptoms of dizziness, dysarthria, dysmetria, and weakness of the legs, there have been numerous case reports of unusual manifestations in pontine strokes such as restless leg syndrome and tremulousness.
Methods: Here, we present a case of a 72-year-old woman with an atypical sequelae of symptoms following an acute left pontine cerebrovascular accident.
Results: A 72-year-old woman with a history of meningioma and breast cancer on Tamoxifen presented to the ED complaining of difficulty speaking. The night prior to presentation, the patient reported that she began experiencing dizziness, nausea/vomiting, as well as difficulty with word-finding. She reported falling and hitting her head secondary to dizziness. After the fall, she went to bed and woke up the next morning still experiencing significant difficulty with word-finding, new-onset stuttering, and difficulty ambulating at which point she was driven to the ED by family. Physical examination was remarkable for a flushed/erythematous appearance to the skin, profound generalized tremulousness, significant dysarthria with profound stuttering, vertical nystagmus, left internuclear ophthalmoplegia, and right upper limb dysmetria. Motor function and sensation were grossly intact. NIH Stroke Scale was 3. MRI brain with and without contrast revealed an acute infarct in the parasagittal left dorsal pons. Upon initial presentation the patient’s significant tremulousness, stuttering, and flushed appearance were attributed to anxiety given acute onset of stroke-like symptoms; however, upon review of imaging and cursory review of literature, these unusual symptoms were determined to be rarely reported sequelae of her infarct.
Conclusion: This case presentation adds to existing literature on the unique presentations of pontine stroke. The acute behavioral changes including restlessness and facial flushing that were initially thought to be secondary to acute anxiety rather than a neurological impairment exemplifies the range of presentations that can be misdiagnosed due to incongruence in comparison to typical stroke-like symptoms. This case highlights the importance of ensuring that medical professionals are aware of the more unusual presentations that may accompany pontine stroke to decrease patient complications and improve outcomes.
Audience Take Away Notes:
- Typical presentations of pontine strokes and warning signs to look for
- How to recognize the unique sequela of a pontine stroke including symptoms mimicking psychological or behavioral causes.
- How to avoid the representativeness heuristic to expand potential differential diagnosis in the identification of stroke-like symptoms.
