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Hemiplegia Vegetativa Alterna (HVA) is the clinical condition characterized with ipsilateral Horner’s syndrome (HS) and contralateral hemi-hyperhidrosis and is mainly used to define the condition at stroke patients with posterior cerebral artery (PCA) or middle cerebral artery (MCA) occlusion (1,2). The cases with involvement of uncrossed excitatory and crossed inhibitory hypothalamo-spinal sympathetic pathways have been also defined as HVA by the researchers (1). However, as the lesions straggle or cover a large area, it was not possible to identify a certain anatomical localization, which would explain the clinical condition. Our case is a combination of the previously presented cases and includes both MCA and PCA occlusions. A 39-year-old female patient was referred to the neurology intensive care unit (ICU) with loss of consciousness, hemiplegia on the right side of the body, and aphasia. She was somnolent in her neurologic examination. She had no responses to verbal stimuli and localize painful stimulus with her left side. It was impossible to have cooperation with the patient due to the mixed aphasia and her pupils were anisocoric (right>left), and pupillary light reflex can be taken. In the primary position, eyes and head were deviated to the left side. Patient had right central facial paralysis, and muscle strength of right upper and lower extremities were 1/5. Nevertheless, in her daily follow-ups, in addition to anisocoria of her left eye rima oculi was narrow compared to her right rima oculi. Autonomic disturbance was detected in the form of hypohidrosis in the left half of face, and hyperhidrosis in the right half of body; especially in the right half of face and in the right arm reaching out to the elbow (Figure 1). In the brain CT (BCT), there was a large infarct in the left MCA and PCA area making a distinctive shift effect to the opposite hemisphere (Figure 2). In the cranial MRI taken 15 days later, it was observed that this shift effect had disappeared (Figure 3). Atrial fibrillation with high ventricle response was detected at the ECG. The findings at transthoracic echocardiography were as follows; moderateintensity mitral stenosis, valve area of 1.1 cm2, maximum gradient of the valve was 25 mmHg, mean gradient was 15 mmHg, systolic pulmonary artery pressure was 40 mmHg. In addition to the findings above, Wilkins valve score was 7, there wasn’t any thrombosis in the left atrium and left atrial appendix. 95

Hemiplegia Vegetativa Alterna, Kalp Kapak Hastalığının Serebral Bir İşareti Olabilir mi?