Same stroke, same treatment and lower limb weakness, but forget about upper motor neurons!

By Giuseppe Reale, MD – ESO YSPR Committee

Sometimes it seems that stroke treatment is all about time, tissue and recanalization, whatever it takes. However, it is important to remember that danger might be just around the corner, even after a successful recanalization.

A 66-year old man was carried to our Emergency Department 4 hours after the acute onset of right hemiplegia and aphasia. CT-Angiography (CTA) showed a M1 left middle cerebral artery (MCA) occlusion and the patient underwent to systemic thrombolysis followed by mechanical thrombectomy in general anesthesia with right femoral access. When the patient was admitted to the Stroke Unit, he presented only right lower limb weakness, being able to flex the thigh at hip, but not to extend the leg at knee. The right patellar tendon reflex was absent, while the left was elicitable. The segmental weakness pattern and the reflex asymmetry suggested a femoral neuropathy. CTA of lower extremities excluded the presence of iliacus hematoma or femoral artery aneurysm. The patient had a spontaneous recovery of the neurological deficits within one week. The electromyography performed three weeks later did not show any finding of denervation at the quadriceps muscle, suggesting a previous femoral neuropraxic block.

An 82-year old woman with the same symptoms and radiological findings of the previous patient underwent thrombolysis and thrombectomy with right femoral access in general anesthesia.

When transferred to the Stroke Unit, she presented just a mild drift of the right lower limb, but the day after she developed a complete plegia of the right lower limb associated with “mild pain and an unpleasant cold sensation”. The right lower limb was cold and distal pulses were absent. CTA of the lower extremities demonstrated a pseudoaneurysm of the common femoral artery, associated with distal arterial occlusion. The patient underwent emergency femoral endarterectomy without any complication.

Mechanical thrombectomy-related serious adverse events at the angiography puncture site are uncommon but include access site hematoma and pseudoaneurysm, arterial perforation, and arterial dissection. Other complications described after femoral artery catheterization are iliacus hematoma with femoral neuropathy or femoral neuropathy alone1.

As seen, some of the aforementioned complications can mimic a neurological deficit coherent with the stroke syndrome. Keeping in mind this, an accurate neurological and clinical evaluation might be helpful in identifying signs suggesting such complications (in our case, pulselessness, low temperature or lower motor neuron signs).

  1. Jadhav AP, Molyneaux BJ, Hill MD, Jovin TG. Care of the Post-Thrombectomy Patient. Stroke. 2018;49:2801-2807