Objective:

Describe a case of acute unilateral proximal arm weakness not explained by a cerebellar infarct, where the patient’s history and exam prompted focused imaging that revealed a concurrent anterior spinal cord stroke.

Background:

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Design/Methods:

N/A

Results:

A 64-year-old male with a history of hypertension, diabetes, and renal transplant presented after an episode of transient quadriparesis followed by persistent left arm weakness, for which he received Tenecteplase due to suspicion for acute stroke. Subsequently, he continued to exhibit isolated proximal left arm weakness without other detectable neurological deficits. CT angiography of the neck showed proximal right V1 occlusion from multifocal severe calcified atherosclerosis, and MRI brain revealed a large right cerebellar infarct. The dissociation between the patient’s clinical presentation and radiographic findings prompted further imaging. MRI c-spine showed a diffusion restricting lesion with concurrent T2 hyperintensity in the gray matter of the left anterior spinal cord at the level of C3-C4, consistent with acute infarct. We suspect that this patient had an athero-embolic event originating from the proximal right vertebral artery leading to concurrent anterior cervical spinal infarct (through the anterior spinal artery) and right cerebellum infarct (through the right PICA).

Conclusions:

This case highlights the importance of localization based on clinical history and neurological exam in making an accurate diagnosis. The acute painless quadriparesis raised concern for transient anterior cervical cord ischemia, and the subsequent isolated unilateral proximal arm weakness suggested ischemia to the rostral anterior cervical cord, which MRI corroborated. Confirming the etiology of the patient’s arm weakness through clinical reasoning helped clarify stroke etiology (athero-embolic event), saved him from further unnecessary testing such as EMG/NCS, and likely has implications on his motor recovery prognosis (usually less favorable in spinal cord infarct). Neurology remains a primarily clinical specialty, and use of neuroimaging must be hypothesis driven.