Edgar R. Lopez-Navarro et al. report the case of a 58-year-old male with a history of arterial hypertension who presented with numbness on the right side of the face and in the right arm, dysphonia, dysarthria, and dysphagia. MRI showed an acute ischemic lesion in the medulla oblongata and cerebellum on the left side. Later, the patient developed mild left sensorimotor hemisyndrome and was seen to be bradycardic subsequent to intense massage of the right side of the neck to relieve neck pain. Plaques in the right ICA and carotid web was seen in the CT and MRI demonstrated a watershed-type stroke on the right side.
A 58-year-old, right-handed white male presented to our emergency room after he woke up with numbness on the right side of the face and in the right arm, dysphonia, dysarthria, and dysphagia. His past medical history was only significant in terms of arterial hypertension. The patient was an employee in a manufacturing plant; personal habits included occasional alcohol consumption, with no history of tobacco or drugs. At the time of admission, he was on aspirin 100 mg daily (indication was unclear). The family history was unremarkable. In the emergency room, the initial systolic blood pressure was 223 mmHg, heart rate was 85 beats per minute, and body temperature was 36.6 °C. In the neurological examination, we found a right sensory brachiofacial syndrome, moderate to severe dysarthria and dysphonia, and dysphagia, with National Institutes of Health Stroke Scale score of 3. Based on suspected brainstem infarct, and following our institutional wake-up stroke protocol, magnetic resonance imaging (MRI) was performed, which showed an acute ischemic lesion in the medulla oblongata and cerebellum on the left side; the patient was outside the therapeutic window for intravenous thrombolysis and was transferred to our stroke unit. Laboratory results showed normal renal and liver function as well as a normal complete blood count. Total cholesterol was 242 mg/dl and the low-density lipoprotein (LDL) level was 161 mg/dl; the patient was put on statin treatment for secondary prophylaxis. Antihypertensive therapy was started with ramipril.
Approximately 12 hours after admission, the patient reported nonspecific dizziness and blurry vision; the telemetry monitoring showed bradycardia of 30 beats per minute. A new neurological examination showed no new deficits. After a few minutes, and in the presence of the medical team in the patient’s room, the patient started to massage the right side of his neck with intense circular movements; the telemetry again showed bradycardia of 30 beats per minute, and after a few seconds it showed asystole for 4 seconds. The patient stated that he had been suffering from moderate neck pain on the right side for approximately 2 weeks, which he was able to relieve with self-massage. A few minutes later, the patient developed mild left sensorimotor hemisyndrome. A computed tomography (CT) scan showed no new infarct demarcation, and CT-angiography showed plaques in the right internal carotid artery (ICA) consistent with mild right ICA stenosis; the flow of the right middle cerebral artery was normal, and the CT axial view showed a membrane in the ICA consistent with a carotid web. A carotid dissection was ruled out. Duplex sonography of the carotid showed a flow acceleration up to 187 cm/second, indicating 40% stenosis according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Transesophageal echocardiography showed no pathology. Electrocardiographic monitoring in the stroke unit revealed no atrial fibrillation.
The patient underwent MRI the following day, which showed a watershed-type stroke on the right side.
The patient underwent diagnostic digital subtraction angiography, which showed the known carotid stenosis and carotid web. Given the risk of recurrent stroke with a carotid web, the patient received a carotid stent.
The patient was discharged with mild dysphonia due to the primary brainstem infarct.