Asterixis as a Presentation of Cerebellar Ischemic Stroke
A 58-year-old male with a history of moderate hypertension and treatment with enalapril (20 mg/day) presented to our emergency department with acute headache in both the cervical and occipital regions of left side. About two hours later he developed asterixis of the upper left limb and gait instability. There was no history of alcohol or drug abuse, and no significant past medical or surgical history. History did not reveal symptoms consistent with depression and/or anxiety, and the patient was only taking enalapril. Neurological examination showed gait instability. Biochemical tests, including serum ammonia, ceruloplasmin, and hematological tests, were normal. Blood pressure was 140/80 mmHg and electrocardiogram showed a sinus rhythm (72 beats/min). Baseline electroencephalogram disclosed mild, generalized, background alpha activity. Ultrasound of the neck was normal. Computer tomography of brain did not reveal structural lesions or abnormalities. The hyperkinetic movement disorder diminished in intensity and was observed as a pattern of asterixis only when the hands were stretched. Over the next 3 days, the asterixis disappeared and neurological examination revealed a weakness in the upper left limb (IV/V on the 0–V Medical Research Council scale). Magnetic resonance imaging (MRI) of the brain disclosed cerebellar infarctions in the left superior cerebellar artery region (). Because angio-MRI did not reveal abnormality, we started the patient on aspirin (100 mg/day). Five days later, clinical examination revealed a weakness in the upper left limb (IV/V) with slight gait instability and the patient was discharged. Clinical evaluations performed one month later did not reveal any signs of neurological lesions.