Supplementary Motor Area Stroke Mimicking Functional Disorder
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A 52-year-old right-handed women was referred from an outside hospital with a diagnosis of stroke. On arrival at our hospital, her National Institutes of Health Stroke Scale was 9 (Table I in the online-only Data Supplement). She had a strength of 0/5 in right upper and lower extremity muscle groups. There was decreased sensation to finger touch in the right lower extremity. She was oriented to person, place, and time. She did not have spatial neglect, motor neglect, apraxia, or abulia. Speech was fluent with intact comprehension, naming, and repetition. Cranial nerve examination was normal.
Interestingly, the patient was able to bear weight and demonstrated a positive Hoover sign that raised suspicion of functional paresis. She was outside the intravenous thrombolysis window but within the thrombectomy window. She had history of nonischemic cardiomyopathy, polymorphic ventricular tachycardia, and had an implantable cardioverter defibrillator.
She underwent noncontrast computed tomographic (CT) examination of the brain along with a multiphasic CT angiography of the intracranial circulation and CT angiography of the neck. The noncontrast examination was negative for acute stroke (Figure 1). However, CT angiography demonstrated an abrupt cutoff in distal portion of the callosomarginal artery branch of the left anterior cerebral artery (ACA; Figure 2). Bilateral common and internal carotid arteries did not show stenosis or atherosclerotic disease. She was admitted to the stroke service for further management. Magnetic resonance imaging of the brain was not done because the compatibility of the implantable cardioverter defibrillator could not be determined. A follow-up noncontrast CT brain was performed after 12 hours which revealed a small nonhemorrhagic acute infarct in the posterior third of left medial frontal gyrus corresponding to the supplementary motor area (SMA; Figure 1). She was empirically started …