Pontine Warning Syndrome | Cerebrovascular Disease | JAMA Neurology | JAMA Network
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October 2008

Pontine Warning Syndrome

Author Affiliations

Author Affiliations: Stroke Research Unit, Division of Neurology, Departments of Medicine (Dr Saposnik) and Medical Imaging (Dr Noel de Tilly), St Michael's Hospital, and Department of Health Policy, Management and Evaluation (Dr Saposnik), University of Toronto, Toronto, Ontario, Canada; and Cerebrovascular/Stroke Division, Beth Israel Medical Center, Harvard University, Boston, Massachusetts (Dr Caplan).

Arch Neurol. 2008;65(10):1375-1377. doi:10.1001/archneur.65.10.1375

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.

Design  Case report.

Setting  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.

Main Outcome Measures  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.