Opalski syndrome (clinical, imaging, and pathophysiological correlations)

Excerpt

A 52-year-old woman with history of alcohol-related cirrhosis and chronic kidney disease presented with 3-day history of dizziness, oscillopsia, and dysphagia. The neurological exam (Supplementary Video 1) demonstrated right Horner’s syndrome, mixed horizontal–torsional left-beating nystagmus, right-sided hemi-palate weakness, pain, and temperature hypoesthesia involving right face, left limbs, and right limb dysmetria. In addition, the patient had upper motor neuron signs on the right side, with lower facial weakness, mild limb weakness, graded 4 out of 5 on the Medical Research Council (MRC) scale, with more prominent involvement of the extensor muscles in the upper extremity and flexor muscles in lower extremity, ipsilateral hyperreflexia, and Babinski sign. Brain MRI demonstrated a DWI-restricted lesion in the right lateral medulla extending from the cervico-medullary junction to the upper medulla. CTA head/neck showed a distal right vertebral artery thrombus (Fig. 1a–f) and evidence of diffuse intracranial atherosclerosis. Remaining stroke workup, including transthoracic echocardiogram, hypercoagulability studies, and malignancy screening, was unremarkable. The etiology of this stroke was intracranial atherosclerosis. The patient was not a candidate for tPA and thrombectomy given the timeline of her presentation. Given concern for worsening of her symptoms during the initial hospital course (“stroke-in-evolution”), and evidence of an acute arterial occlusion, decision was made to start early systemic anticoagulation, based on clinical practice at our institution. The patient was later discharged on a 6-month course of apixaban, and then switched to aspirin as secondary stroke prevention.

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