Capsular warning syndrome—a case of atrial fibrillation and corona radiata infarct

Abstract

Background Capsular warning syndrome (CWS) is a rare clinical syndrome characterised by recurrent and transient episodes of focal neurological deficits with high risk of infarction. The exact physiological mechanism of CWS remains unclear but is most commonly believed to be a result of haemodynamic insufficiency in diseased, small penetrating vessels. There are no defined treatment guidelines or established effective therapy. Case presentation We describe the case of a 65-year-old man who presented to the emergency department with recurrent episodes of dysarthria coupled with right facial droop and right-sided weakness. Symptoms recurred a total of ten times within a span of 3 h. He had new onset atrial fibrillation. An initial cerebral angiogram showed mild intracranial atherosclerotic disease with no proximal large vessel occlusion or acute infarct. Magnetic resonance imaging 1 h later demonstrated an infarct in the left corona radiata. Conclusions This case illustrates an uncommon etiology of CWS. We will also discuss the lack of consensus in treatment options for CWS to mitigate a complete stroke.

Recurrent transitory attacks with cytotoxic edema could benefit from thrombolysis

“…We read with interest the article by Tan et al about a 65-year-old male with ten transitory ischemic attacks (TIAs) within three hours, clinically manifesting as dysarthria and right-sided hemiparesis, each lasting approximately 10 min [ 1 ]. ECG showed newly diagnosed atrial fibrillation (AF).…”

“…ECG showed newly diagnosed atrial fibrillation (AF). Cerebral computed tomography (CCT) showed an old left, lacunar striato-capsular infarct and computed tomography angiography (CTA) showed only mild atherosclerosis [ 1 ]. Magnetic resonance imaging (MRI) showed a small acute infarct in the left corona radiata three hours after onset [ 1 ].…”

“…Cerebral computed tomography (CCT) showed an old left, lacunar striato-capsular infarct and computed tomography angiography (CTA) showed only mild atherosclerosis [ 1 ]. Magnetic resonance imaging (MRI) showed a small acute infarct in the left corona radiata three hours after onset [ 1 ]. The patient recovered completely under therapy initially with acetyl-salicylic acid (ASS, 300 mg), clopidogrel (300 mg), and “aggressive hydration”, which was replaced by apixaban 10 mg/d three days after onset [ 1 ].…”

“…Magnetic resonance imaging (MRI) showed a small acute infarct in the left corona radiata three hours after onset [ 1 ]. The patient recovered completely under therapy initially with acetyl-salicylic acid (ASS, 300 mg), clopidogrel (300 mg), and “aggressive hydration”, which was replaced by apixaban 10 mg/d three days after onset [ 1 ]. The study is impressive, but several points require discussion.…”

“…The major limitation of the study is that the patient did not have capsular warning syndrome (CWS) [ 1 ]. “Capsule” refers to the internal capsule.…”