Acute onset slurring of speech and deviation of angle of mouth

Case Summary

Final Diagnosis: Acute Cerebrovascular Accident — Right Pontine Ischemic Infarct

Clinical Presentation: Acute onset slurring of speech and deviation of angle of mouth

Presentation Window: Within the thrombolytic therapy window period

The patient presented to the ICU with acute neurological deficits consistent with a brainstem stroke. Prompt clinical assessment and neuroimaging confirmed a right pontine ischemic infarct. The patient was deemed an appropriate candidate for systemic thrombolysis given timely presentation and absence of contraindications.

Treatment Approach

Decision was made to proceed with systemic thrombolysis after multidisciplinary evaluation:

• Urgent CT brain performed to exclude haemorrhagic transformation
• NIHSS scoring documented and eligibility criteria confirmed
• Systemic thrombolysis administered with Tenecteplase (weight-based dosing)
• Continuous neurological monitoring in the ICU post-thrombolysis
• Repeat CT brain at 24 hours to assess for haemorrhagic complications

Outcome / Results

• Complete resolution of slurring of speech following thrombolysis
• Complete resolution of deviation of angle of mouth
• Repeat CT brain (Day 2) — No haemorrhagic transformation detected
• No procedure-related complications observed
• Patient discharged on Day 4 with outpatient rehabilitation and physiotherapy referral

Key Learning & Uniqueness of the Case

This case highlights several important clinical lessons:

• Pontine strokes may present with subtle signs (dysarthria, facial deviation) that can be under-triaged — early recognition is critical.
• Tenecteplase is an effective and convenient single-bolus thrombolytic agent in acute ischaemic stroke within the treatment window.
• Rapid door-to-needle time and multidisciplinary ICU coordination contributed directly to the excellent neurological outcome.
• Complete neurological recovery following brainstem infarct thrombolysis, though uncommon, is achievable with timely intervention.

Confidentiality

All patient identifiable information has been removed in accordance with hospital policy. No personal data, names, MRD numbers, or imaging containing identifiable features are included in this submission.

Dr. Varun Thareja
Department of Neurosciences
Sant Parmanand Hospital, New Delhi
In collaboration with: Dr. Deepansh Gupta
Intensivist, Sant Parmanand Hospital, Kashmere Gate