Pontine warning syndrome.
BACKGROUND
Little is known about stroke mechanisms in patients with fluctuating symptoms and the role of branch atherosclerotic disease.


OBJECTIVE
To report a novel stroke presentation associated with a paramedian pontine infarct due to branch disease with a fluctuating course.


METHODS
Case report.


METHODS
Academic research. Patient A 63-year-old man with hypertension, diabetes mellitus, and dyslipidemia was seen with fluctuating right-sided weakness and dysarthria. He had had 2 episodes of complete bilateral horizontal conjugate gaze palsy with unimpaired consciousness lasting for 5 minutes each. His pupils were 4 mm and were equal and reactive to light. Vertical gaze and convergence were preserved. His neurologic status fluctuated between 3 and 15 on the National Institutes of Health Stroke Scale.


METHODS
Results of computed tomographic angiography, perfusion, and magnetic resonance imaging.


RESULTS
Intravenous tissue plasminogen activator was administered within a 3-hour window. Fluctuations in motor weakness persisted for 12 hours after receiving thrombolytic therapy. Neuroimaging showed an acute left paramedian pontine infarct with a patent basilar artery.


CONCLUSIONS
Branch disease is a common mechanism in pontine infarctions. We coined the term "pontine warning syndrome" to characterize recurrent stereotyped episodes of motor or sensory dysfunction, dysarthria, or ophthalmoplegia associated with a high risk of imminent basilar artery branch infarction and a permanent deficit resembling those of capsular warning syndrome.
Saposnik
Gustavo
G
Stroke Research Unit, Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, 55 Queen St E, Ste 931, Toronto ONM5C1R6, Canada. saposnikg@smh.toronto.on.ca
Noel de Tilly
Lyne
L
Caplan
Louis R
LR
D001488:Basilar Artery / Q000473:pathology / Q000503:physiopathology; D020526:Brain Stem Infarctions / Q000175:diagnosis* / Q000473:pathology / Q000503:physiopathology; D004401:Dysarthria / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis* / Q000473:pathology / Q000503:physiopathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009069:Movement Disorders / Q000209:etiology* / Q000503:physiopathology; D015835:Ocular Motility Disorders / Q000209:etiology* / Q000503:physiopathology; D010291:Paresis / Q000209:etiology / Q000503:physiopathology; D011149:Pons / Q000098:blood supply* / Q000473:pathology / Q000503:physiopathology; D011237:Predictive Value of Tests; D011379:Prognosis; D014057:Tomography, X-Ray Computed; D014715:Vertebrobasilar Insufficiency / Q000175:diagnosis* / Q000473:pathology / Q000503:physiopathology