A case of „Spectacular Shrinking Deficit“ – case report and short review of elusive clinical phenomena

Abstract

Spectacular Shrinking Deficit (SSD) is a term attributed by J.P. Mohr to a rare cerebrovascular event defined by a rapid and dramatic improvement of major hemispheric stroke syndrome. It is presumed to be caused by the migration of initially embolic occlusion of an internal carotid artery or middle cerebral artery to its distal branches. It is only reported in several case reports, and case series with differing criteria of what defies an SSD meaning that its presumed prevalence rate of 7-14% of major hemispheric stroke syndromes could be an overestimation. It is usually associated with the cardioembolic cause of stroke, and it has a higher prevalence rate in younger patients, males, and nondiabetics. Our case is a 58 -year old male who presented to our ER with a major hemispheric stroke syndrome (deviation of head and eyes on the right side, central facioparesis on the left, left hemiplegia, and left hemineglect, NIHSS 16) 30 minutes after symptom onset. He was aggressive, insisting nothing was wrong with him. His initial brain CT showed acute ischemic changes in the right temporooccipital region with an inadequate filling of distal branches of the right MCA shown on CT brain angiography. His symptoms spectacularly improved in our ICU (NIHSS 0) 51 minutes from symptom onset negating the need for thrombolysis. Except for one positive Beta -2 GPI test his detailed laboratory tests, 24h Holter ECG, TTE, carotid, and vertebral artery ultrasound were noneventful. He had no cognitive or neurological deficit. He denied the possibility of performing TEE and prolonged cardiac monitoring. Control brain MRI 4 days and 4 months later confirmed moderate ischemic changes of the right insular, temporal, and occipital cortex. Studies report that spontaneous recanalization usually happens in 17% of patients but does not correlate with TIA. This is the first report of an SSD with moderate ischemic stroke and no leftover neurological deficit. Other case series report moderate ischemic stroke SSD with a small residual neurological deficit (NIHSS 2-4). Perhaps mood changes can be associated with selective neuronal loss found in animals and patients suffering transient occlusion of the brain artery. The cardioembolic cause can in certainty be excluded with TEE and prolonged cardiac monitoring.