A 31-year-old male with no significant history presented to the emergency department (ED) with left arm and leg weakness accompanied by headache and right-sided neck pain. The day prior while playing basketball, he sustained a blow to the right lateral neck during a collision with the knee of another player. That night, the patient had left arm and leg weakness accompanied by a facial droop, the latter resolving prior to presentation to the ED. In the ED, the patient had localized tenderness over the paracervical muscles and residual left arm and leg weakness. He had no carotid bruit, and the remainder of his physical exam was unremarkable. A brain computerized tomography (CT) scan without contrast (Figure 1) and CT angiogram (CTA) of the neck (Figure 2) were normal as read by an experienced neuroradiologist. His echocardiogram was also normal. He was diagnosed with a concussion and possible cervical radiculopathy and discharged with cyclobenzaprine, methylprednisolone, and analgesics.
Four days after the injury occurred, the patient presented with persistent dizziness, right-sided headache, and left-sided weakness. During the physical exam a left-sided pronator drift was noted. Magnetic resonance imaging (MRI) of the brain demonstrated an acute ischemic infarct in the right frontoparietal lobe, superior aspect of posterior right temporal lobe, and posterior aspect of the right insular cortex with a 4 mm right-to-left midline shift (Figure 3). MRI of the neck showed no evidence of cervical vertebral body fractures. Bilateral carotid ultrasound and CTA of the brain and neck including the skull base were negative for dissection and stenosis of the carotid bulbs and vertebral arteries, respectively. Aspirin therapy was initiated and the patient was discharged home with outpatient rehabilitation one week later. During follow-up, five months after injury, the patient continued to have intermittent left arm numbness and headaches along with comprehension difficulty, intermittent confusion, and trouble sleeping.