Objective:

To describe a rare case of post-infectious CNS vasculitis presenting as acute ischemic stroke, new-onset status epilepticus, and locked-in syndrome which showed remarkable recovery after immunomodulatory therapy.

Background:

CNS vasculitis is an uncommon but potentially reversible cause of neurologic injury with varied presentations. The simultaneous occurrence of acute ischemic stroke and new-onset status epilepticus is infrequent. Early recognition and treatment are essential for recovery.

Design/Methods:

Single-patient case report summarizing clinical presentation, diagnostic evaluation, and therapeutic response.

Results:

A 48-year-old female with no vascular risk factors and a flu-like illness two weeks prior presented as a stroke alert with acute aphasia and new-onset status epilepticus. CT angiography showed short-segment basilar artery stenosis, and she received intravenous thrombolysis for presumed ischemic stroke. Despite eventual seizure control with levetiracetam, lacosamide, and midazolam infusion, she remained ventilator-dependent and with clinical locked-in syndrome with preserved awareness. MRI revealed bilateral pontine and right parietal infarcts with petechial hemorrhages. Cerebrospinal fluid showed markedly elevated protein with negative infectious and autoimmune panels, prompting initiation of high-dose corticosteroids. Digital subtraction angiography confirmed multifocal narrowing and distal vessel “beading” consistent with CNS vasculitis. Five sessions of plasmapheresis led to successful extubation, marked neurologic improvement (all extremities at least 3/5 in strength by discharge), and near-complete resolution of arterial vessel changes in follow-up studies.

Conclusions:

This case illustrates a rare manifestation of post-infectious CNS vasculitis presenting with new onset status epilepticus and multifocal ischemic strokes in a previously healthy patient without traditional vascular risk factors. Maintaining a high index of suspicion and initiating early immunomodulatory therapy can enable meaningful recovery, even in severe presentations resembling locked-in syndrome.