1405 - Accelerated cognitive decline from isolated hippocampal stroke: case report

Case Diagnosis: An 89-year-old woman with CVA

Case Description: The patient with a history of pAfib, hypertension, and bilateral CAS presented to ED for altered mental status, slurred speech, and unstable gait. MRI revealed an isolated acute infarct of the left hippocampus. MRA of head and neck showed 70% stenosis of the bilateral internal carotid artery with P2 occlusion. She was treated with antiplatelets and statin and discharged to ARF nine days later. Prior to stroke, the patient was fully oriented and independent with ADLs but was experiencing cognitive decline over the past two years such as forgetfulness and getting lost. On admission, the patient was only oriented to self. She scored 8/30 on the MOCA with deficits in visuospatial/executive functioning, naming, attention, language, delayed recall, and orientation. Repeat MOCA prior to discharge was unable to be completed due to agitation. Her cognitive deficits minimally improved requiring eventual discharge to SAR.

Discussions: Cerebrovascular disease is a common etiology of major neurocognitive disorder, however, isolated hippocampal infarct is rare. One study found that only 0.3% of patients with first-ever ischemic stroke had acute isolated ischemic hippocampal lesions. The hippocampus, supplied by the posterior cerebral artery and anterior choroidal artery, is involved in declarative, episodic and semantic memory. The main feature of isolated hippocampal infarcts is disorientation, which often improves within two weeks after admission. Other symptoms include memory difficulties in autobiographical, recent, and working memory. Hippocampal infarcts can be considered a subtype of vascular major neurocognitive disorder in the setting of acute onset cognitive deficits in complex attention and memory.

Conclusions: Isolated hippocampal infarcts with memory deficits are rarely documented. Further characterization of this disease process is critical for efficient treatment and better outcomes.