A 76-year-old right-handed woman presented with sudden right-sided weakness and mutism. Examination revealed transcortical motor aphasia, right arm apraxia and spasticity, and right leg hemiplegia. She demonstrated abulia, anosognosia, and emotional lability. CT angiogram demonstrated a left pericallosal artery occlusion (Figure 1). The patient received tPA. MRI demonstrated an infarct spanning the left supplementary motor area (SMA) and anterior cingulate cortex (Figure 2).1
MRI confirms the area of infarct involving the supplementary motor area (red asterisk), cingulate cortex (white asterisk), and sparing of the primary motor cortex (black asterisk), with corresponding DWI restriction. Axial DTI sequences confirm the sparing of corticospinal tracts (thick arrow) and commissural fibres (thin arrow).
Acute onset of aphasia, contralateral dyspraxia, and motor hemineglect should raise suspicion for SMA territory infarct while anterior cingulate involvement may result in acute spasticity and neuropsychiatric symptoms; these are rarely reported simultaneously in ACA infarcts.1 Atypical ACA stroke syndromes are rare; clinical recognition avoids misdiagnosis.1,2
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Footnotes
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↵* These authors contributed equally to this work as first authors.
Teaching slides links.lww.com/WNL/B632
- © 2021 American Academy of Neurology
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