Capsular warning syndrome in a patient with recurrent artery of Heubner infarction

Case contributed by Dr René Pfleger

Presentation

Presenting to ER with headaches and light dizziness after minor head trauma. Further details temporarily withheld.

Patient Data

Age: 35-40 years
Gender: Male

CT study of the head reveals no acute abnormalities. 

There is loss of substance in the rightsided head of the caudate, anterior putamen and anterior limb of the internal capsule with slight secondary dilatation of the right lateral ventricle, cornu frontale and consistent with infarction in the territory of right recurrent artery of Heubner (RHA).

There is intracranial atherosclerosis of the intraclinoid segment of both internal carotid arteries (ICA).

No further evidence of atherosclerotic disease, no evidence of former surgery.

Bones, paranasal sinuses and mastoid are unremarkable except slight polypoid mucosal thickening in anterior wall of left maxillary sinus.

Conclusion

No acute intracranial abnormality.

Chronic changes comprising lacunar infarction of right recurrent Heubner´s artery territory and 

intracranial atherosclerosis of both ICA - correlation with patient history, inherited disposition and various blood test including lipid profile recommended.

Annotated images depicting anomalies.

MRI

After interim loss to follow-up, the patient was referred for imaging three years later due to repetitive symptoms comprising left-sided facial droop and simultaneous weakness and numbness of the left arm and leg

MRI performed as multimodal stroke protocol without evidence of diffusion restriction, acute bleed or thrombosis. No microbleeds. Loss of substance with reactive gliosis corresponding to right artery of Heubner infarction, unchanged. Remainder of cerebrum, brainstem and cerebellum unremarkable. No overt malignant or focal changes.

Incidental note of polypoid mucosal thickening rostrally in left maxillary sinus.

Conclusion

No acute intracranial abnormalities.

Sequel to right artery of Heubner infarction, unchanged in character and size.

 

Chronic lacunar infarction of right recurrent artery of Heubner as depicted on T2 FLAIR.

Case Discussion

The symptom complex of fluctuating unilateral motor, sensory or sensorimotor deficits simultaneously affecting the face, arm, and leg (i.e. clinically localized to the internal capsule) is referred to as capsular warning syndrome (CWS). While the exact pathomechanism is not fully understood and with the syndrome being rare (~1,5% of transient ischemic attacks TIA), its often poor prognosis with a 7-day risk of subsequent stroke equating 60% necessitates both clinicians and radiologists to be cognizant of this entity. 

With a history of incidental intracranial atherosclerotic disease (IAD) and lacunar infarction of the right recurrent artery of Heubner (performed at St. Elsewhere and not reacted upon) as visualized on brain computed tomography CT performed due to minor head trauma (MHT) three years before, the patient later presented to the ER with repetitive sensorimotor deficits in the left side of the face, left arm and left leg i.e. description fitting CWS. Multimodal mMRI stroke protocol (DWI, T2-WI, T2*-WI and T2 FLAIR) performed in ER setting revealed no acute changes including absence of diffusion restriction, indicating intermediate risk of subsequent complete stroke. Ultrasonography with pulse waved Doppler PWUS of the extra cranial cervical vessels and consultation by a cardiologist performed in a subacute setting were without evidence of cervical large vessel or cardiac disease. 

Cholesterol lowering drugs and anti platelet therapy were initiated timely and the patient was asymptomatic at both one- and two-year follow up. 

With diagnostic workup as well as therapy in CWS grossly dependent of local/national guidelines, these must be tailored individually and are beyond the scope of this discussion.

Key points:

  • the symptom complex of fluctuating unilateral motor, sensory or sensorimotor deficits simultaneously affecting the face, arm and leg, also referred to as capsular warning syndrome (CWS)carries a poor prognosis with a 7-day risk of subsequent stroke equating 60%, necessitating both clinicians and radiologists to be cognizant of this entity
  • while MRI may be preferable owing to its higher sensitivity, timely (< 7 days) cross-sectional imaging (by either CT or MRI) as well as risk-stratification and initiation of tailored therapy are of utmost importance to prevent devastating outcome

 

 

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Case information

rID: 34333
Case created: 15th Feb 2015
Last edited: 19th Sep 2015
Inclusion in quiz mode: Excluded

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