Delayed Capsular Warning Syndrome after a Recurrent Capsulothalamic TIA

We present a 57-year-old male who presented a right arm paresthesia lasting for 5 minutes. Two hours later he suffered from a right faciobrachial paresthesia lasting for 10 minutes. Cranial MRI didn’t reveal ischemic lesions. The patient was discharged home with acetyl salicylic acid and atorvastatin. Three months later the patient presented two episodes of a right faciobrachial paresthesia lasting for 10 minutes, separated by a few minutes. The patient came to the Emergency Department (ED), where he presented a new episode without a complete recovery. While the patient was in the ED, he presented a clinical fluctuation on two occasions this extending to the leg hypoesthesia and a slight right hemiparesis. Neurological status at the time of admission showed a right faciobrachial hypoesthesia. Cranial MRI at this time showed a left capsulothalamic stroke. Antithrombotic treatment was changed to clopidogrel. Up to the present, he remains clinically stable. This case shows that capsular warning syndrome (CWS) is a broader syndrome than initially described. The clinical evolution of our patient (a CWS that resulted in a left capsulothalamic stroke three months after a recurrent capsulothalamic TIA) may points toward an unstable hemodynamic process with an underlying high degree atherosclerotic disease in small intracranial vessels, such as may occur in large artery disease, such as carotid artery high degree stenosis.