Acute cerebral infarction presenting with weakness in both legs and one arm.

A 48-year-old white man who was healthy previously presented from an outside hospital with weakness of the bilateral lower extremities and right upper extremity. He awoke at 3 Am in morning on the day of initial presentation with unexplained urinary incontinence and diaphoresis. His symptoms resolved, and he went back to bed. At 7 Am, he dropped his daughter off at daycare; this was the last known normal time. At 7:15 Am, he was stopped by the police because of erratic driving. Although details of his condition at that time are sketchy, it seems, he was not following commands. Paramedics were called, and he was taken to a community hospital where he was described as shivering, staring, mute, and not following commands with left gaze deviation and ple-gia of both lower extremities and the right upper extremity; the left arm moved purposefully with full strength. He had an episode of vomiting and difficulty managing his secretions. Computed tomogragphy scan of the head was unremarkable, and the diagnosis remained uncertain. Because of his shivering , he was loaded with phenytoin for possible seizures and transferred to a tertiary care hospital for further evaluation. On arrival, he was not following any commands and found to have copious oral secretions that prompted emergent intu-bation for airway protection. As in the outside hospital, both lower extremities and the right arm were plegic. The left hand moved purposefully. He had extensor posturing of both lower limbs and the right upper limb with noxious stimuli. There was sustained clonus and bilateral plantar extension reflexes present in both lower limbs. Emergent magnetic resonance imaging of the brain showed an acute to subacute infarction in the bilateral frontal lobes, bilateral basal ganglia, and left frontal operculum. magnetic resonance angiography showed that the right A1 segment of the anterior cerebral artery (ACA) was absent and that both ACA territories were supplied by the left anterior circulation (Figure 1A). Intracranial and extracranial magnetic resonance angiography was otherwise unremarkable. No intravenous tissue-type plasminogen activator was administered as the patient was beyond the 4.5-hour therapeutic time window. Endovascular treatment was not pursued because of the large infarct volume. Follow-up magnetic resonance imaging the next day showed a completed left middle cere-bral artery and bilateral ACA infarctions (Figure 1B). Because of his large infarct volume, he required hemicraniectomy for malignant cerebral edema. The patient required a tracheostomy and percutaneous gastrostomy tube for feeding. …