Hypertrophic Olivary Degeneration after Pontine Hemorrhage: A Cause of Delayed Neurological Deterioration

Case Report A 71-year-old female suffered a sudden onset of diplopia, dysarthria and paresthesias of the left hemiface and the upper left extremities. She had hypertension and dyslipidemia. Upon admission, the patient showed a right IV cranial nerve palsy, skew deviation, right internuclear ophthalmoplegia, dysarthria, left central facial palsy, left hemihipoestesia, right appendicular ataxia and gait ataxia. Brain CT showed two acute intraparenchymal hemorrhages, a larger one in the pontine tegmentum adjacent to the right superior cerebellar peduncle, and a second one in the homolateral basis ponti. Brain MRI (on day 3) confirmed these two subacute hemorrhages, which involved the central tegmental tract ( fig. 1 a, d). The patient was discharged 11 days later with a modified Rankin Scale (mRS) score of 4. During the following weeks, the patient improved and she could walk with unilateral assistance (mRS score 3). Background In patients who suffer acute stroke, the improvement of neurological deficits varies. Late-onset neurological worsening, after an initial clinical improvement, may be caused by prolonged focal motor seizures [1] , cognitive decline and dementia [2] , depression and apathy [3] , emotional disturbances [4] and fatigue [5] . Received: February 19, 2013 Accepted: May 15, 2013 Published online: September 11, 2013