Bilateral Anterior Cerebral Artery Infarction: A Rare but Catastrophic Stroke Syndrome
I. Case Report A 63 year old right handed man was referred to the emergency unit of a hospital in Calabar, Nigeria, with symptoms of sudden weakness of the left lower limb of 6 days duration, right lower limb weakness of 5 days duration, and loss of consciousness during the last 3 days. His problems started with sudden severe numbness and weakness of the left lower limb on waking in the morning. There was no preceding headache, vomiting or seizures. A day later, the patient noticed similar symptoms on the right lower limb though symptoms remained worse on the left limb. There was no other relevant past medical history. The patient was diagnosed with hypertension seven years prior to the current presentation, and was treated with Ramipril and Amlodipine; however, he was not compliant with follow up hospital visits. For the symptoms above, he was admitted into a peripheral centre on the same day of symptoms onset and received antihypertensive medication, dextrose and sedatives because of restlessness. His blood pressure ranged between 160 180/80 100mmHg. The patient lapsed into unconsciousness 3 days after admission and was thus transferred to our larger centre in the same town. On examination, he was unconscious, febrile (38.8 C) with no pallor, anicteric, and acyanosed. His Glasgow coma scale (GCS) was 3/15. The pupils were normal in size but showed a sluggish reaction to light, doll's eye movement was intact and there was no obvious cranial nerve VII palsy. He had reduced tone on both upper limbs, increased tone on the left lower limb and reduced reflexes on both upper and lower limbs. There were no signs of meningeal irritation or frontal release signs. His heart rate was 88 beats per minute and regular with a blood pressure of 210/90mmHg. There was cardiomegaly with a 4th heart sound but without any murmurs. He had three (4X3cm) infected decubitus ulcers on the gluteal area. Investigations revealed normal serum glucose levels (8.3mmol/l) leucocytosis (15.2 X109/ul) with neutrophils accounting for 66% Lipid profile was deranged showing total cholesterol of 7.70mmol/l and LDL cholesterol of 4.98mmol/l. There was hyperuricemia with uric acid level at 0.77mmol/l. INR was 1.16. A noncontrast CT scan of the brain revealed acute bilateral cerebral infarctions in the anterior cerebral artery territories. A diagnosis of coma due to bilateral ischemic anterior cerebral artery stroke complicated with infected decubitus ulcers was made. The patient was managed conservatively with intravenous mannitol and frusemide, normal saline, vitamin B complex, vitamin C, intravenous ceftriaxone (2g daily) supportive oxygen therapy, daily wound dressing and regular turning as well as application of compression stockings on the limbs. A nasogastric tube was inserted, through which he received oral dipyridamole, vasoprin, artovastatin, allopurinol and feeding. His condition however did not improve and the GCS remained 3/15 until his death on the fifth day of admission to our centre.