Clinical Reasoning: A 71-Year-Old Man Presenting With Acute Onset Dysarthria and Dysphagia

A 71-year-old man presented to the emergency department with sudden onset of dysarthria and dysphagia. The patient had arterial hypertension and unspecified tachyarrhythmia. Recently, he was evaluated for difficulties in fine motor skills and rest tremor of the left hand and he was diagnosed with vascular parkinsonism. His medical history was otherwise unremarkable. He denied recent fever or infections. The neurologic examination revealed a severe dysarthria, a positive finger-to-nose test on the left side, a slight hypomimia, and postural and rest tremor of the left arm. The patient was able to walk independently and Romberg sign was negative. Deep tendon reflexes were normally elicitable and symmetric and plantar responses were flexor. Light touch, pinprick, position, and vibration sense were intact. Blood pressure was mildly elevated (160/90 mm Hg), heart rate was rhythmic, and the patient was afebrile. Given the abrupt symptom onset, a cerebrovascular etiology was first suspected. The patient underwent urgent brain CT scan, which was unremarkable, and CT angiography (CTA) (figure). After the CT scan, the symptoms progressively improved and then completely subsided in about 1 hour.