Progressive lacunar stroke presenting as cheiro-oral syndrome, dysarthria and hemiataxia

Abstract

Context: Lacunar infarcts are small infarcts caused by occlusion of a single penetrating vessel, affecting mostly the basal ganglia, subcortical white matter and pons1. Around 20-30% of patients may progress symptoms over hours to days, and this presentation is associated with disability and poor prognosis2. Case report: A 70-year-old man with history of smoking, hypertension and a previous right occipital stroke reported right upper lip paresthesias since awakening. In 2-hours the right perioral region and his right hand were affected. After 3-hours he noted slurred speech. After 4-hours, imbalance was added to the previous symptoms. On admission, NIHSS was 4, mostly by previous left hemianopia, new right arm ataxia and cerebellar dysarthria. There were no weakness or sensory déficits. Brain MRI showed a subacute lacunar stroke in the left thalamus. Discussion: Thalamic lacunar strokes can present in a wide range of symptoms depending on the affected nuclei. The ventral posterior lateral nucleus (VPLn) and the ventral posterior medial nucleus (VPMn) carries sensory input from the contralateral body and face, respectively3. Cheiro-oral syndrome (COS) is considered a pure sensory thalamic lacunar syndrome with symptoms that affect the face, hand and/or foot, but may be accompanied by ipsilateral ataxia if the ventral lateral nucleus is also affected4 . Although classically associated with thalamic ischemic lesions, there are descriptions of hemorrhagic strokes5 and multiple different affected regions presenting as COS, including brainstem5 , internal capsule6 , operculum7 , cortex8 , corona radiata9 and thalamus10. Early recognition and diagnosis is essencial to institute adequate early treatment and secondary prophylaxis.