Often Overlooked but Critical

Case Description A 37-year-old previously healthy right-handed woman presented with sudden onset of left facial droop, left hemiparesis, and headache after a water park ride. She was evaluated within 3 hours of symptoms and received intravenous tissuetype plasminogen activator. Computed tomographic angiography demonstrated right internal carotid artery dissection, and she underwent emergent carotid stenting. The following day, computed tomography revealed infarction in the right superior temporal gyrus, insula, and caudate head. At discharge, she had a 4/5 left hemiparesis and left hemisensory loss. She was described as having normal mental status. Subsequent outpatient evaluation showed continued motor recovery but persistent cognitive dysfunction with superimposed depression and anxiety. Neuropsychiatric testing 1 year poststroke showed her performance on the Wechsler Adult Intelligence Scale was in the 47th percentile, mildly reduced attention and executive function, borderline visual construction skills, and abnormal prosody of speech. Depression and anxiety were noted. Vocational and rehabilitation training was recommended with hopes she would return to work with gradually increased responsibility. She declined training and remained unemployed. During the following years, she complained of persistent cognitive and sensory deficits. Her husband complained of her altered personality and failure to resume her normal activities. Her marriage eventually failed. Repeat neuropsychiatric testing 3 years later showed worsened attention and executive function scores, including abstract reasoning, weakness in encoding of auditory information, and persistent sensory aprosodia. She reported increased psychological stress and anhedonia and was taking an antidepressant and seeing a psychologist. Repeat neuropsychiatric testing in 2010 showed that her Wechsler Adult Intelligence Scale had declined to the 19th percentile. It was felt that her worsening score was because of increased depression in the context of marital and employment stressors. Magnetic resonance image scan at that time showed her remote right middle cerebral artery infarction (Figure).