Bilateral Frontal Cerebral Infarctions Presenting as Ascending Weakness: Case Report (P1.023)

OBJECTIVE: We describe a case of bilateral frontal cerebral infarctions presenting as ascending weakness highlighting anatomic variants of the anterior cerebral artery associated with atypical clinical presentations. BACKGROUND: The anterior cerebral artery (ACA) typically consists of two paired arteries divided into five segments that supply the frontal and parietal lobes as well as portions of the basal ganglia and internal capsule. There are anatomic variants of the ACA that can lead to bilateral and symmetric symptoms in the setting of an occlusion. These findings have been described in the literature and if unrecognized can lead to a delay in the diagnosis of stroke. DESIGN/METHODS: Case report. RESULTS: A 68 year-old woman presented with mild weakness and numbness in both feet that progressed proximally over four days to severe weakness, immobility, and urinary incontinence. She was hyperreflexic at the time of presentation, which remained unchanged throughout her hospitalization. Subsequently she was found with atrial fibrillation and a thrombus in an unpaired (azygous) A2 ACA segment accounting for bilateral frontal strokes documented with magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). CONCLUSIONS: To our knowledge there are only a few case reports describing bilateral frontal cerebral infarctions due to a single A2 segment of the anterior cerebral artery. Bilateral cerebral infarctions should be considered in patients with symmetric weakness, especially in those with vascular risk factors who do not have features consistent with an alternative etiology. Reflexes are an important feature in distinguishing between central and peripheral lesions and should be closely monitored in these patients. Timely diagnosis will enable early delivery of thrombolytic therapy to these patients improving outcomes.