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.
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
Gustavo
G
Saposnik
Lyne
L
Noel de Tilly
Louis R
LR
Caplan
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