Physiatrist Memorial Rehabilitation Institute Hollywood, Florida, United States
Case Diagnosis: Post-stroke parkinsonism in setting of left middle cerebral artery stroke
Case Description: An 87 year old male presented as a stroke alert due to left gaze preference, right hemiparesis and aphasia following a fall. Stroke scale of 26 on arrival. Patient received intravenous Alteplase in the emergency department. Imaging significant for occlusion of cervical left internal carotid artery (ICA) and hypoperfusion of left middle cerebral artery (MCA) territory which required emergent mechanical thrombectomy of the left ICA and M1 segment of left MCA. Brain magnetic resonance imaging revealed an acute left thalamic infarct with hemorrhagic conversion. Exam remarkable for residual right paresis, left gaze preference and paucity of speech. Additionally, patient noted to have bradykinesia, postural instability, and festinating, crouched gait. His functional status was grossly maximal assistance with mobility and moderate assistance with activities of daily living. A trial of low dose Sinemet was initiated with notable reduction of parkinsonism features.
Discussions: Acute post-stroke parkinsonism (APSP) occurs after 1%-4% of strokes. These movement disorders are frequently encountered when the basal ganglia or their respective connections are affected. In our patient, the thalamic lesion may have affected the striatal-thalamic circuit resulting in parkinsonism features. APSP may be difficult to diagnose clinically as some symptoms may be attributed to psychomotor slowing, clouding the clinical picture. Practitioners must have a high index of suspicion for APSP in patients that develop rigidity, akinesia, motor slowing, and gait impairment after a cerebrovascular accident.
Conclusions: This case report aims to raise awareness regarding APSP as timely diagnosis and treatment could hasten the recovery and prevent worsening of disease progression. Additionally, judicious management with initiation of dopaminergic agents may increase rehabilitation efficacy and quality of life in post stroke patients.
