Victor J. Del Brutto, MD
Early in my neurology training, two cases changed my perspective on the importance of patients’ head positioning during the acute phase of cerebral ischemia. The first was a man in his 60s who presented with a right MCA syndrome associated with an acute occlusion of the ipsilateral cervical ICA. When the patient was transitioned to the CT scan table (flat positioning), initial left homonymous hemianopia, left hemi-neglect, left hemiplegia, and right gaze deviation (NIHSS 17) resolved, leaving just a residual left face droop and left arm drift (NIHSS 3). Once the patient was back to the ED, and despite a constantly elevated blood pressure, the variations on his exam associated with the head of bed flat versus elevated was reproducible.
A few weeks later, I was called to evaluate a lady on her eighth decade of life who developed acute onset right-sided weakness. Initial examination showed right ataxic hemiparesis (NIHSS 4). Brain MRI and MR angiogram showed a tiny DWI-positive lesion on the left ventral pons, as well as diffuse intracranial atherosclerosis including a narrow basilar artery. The patient was loaded with antiplatelet agents and admitted to the Stroke Unit. During the wait time in the ED, the patient stood up from the bed in an attempt to go to the bathroom. According to the nurse report, when the patient stood up, she immediately developed right hemiplegia and right gaze preference. On re-examination, the new worsening deficits persisted (NIHSS 11), and a repeated brain MRI showed progression of the infarct involving now the whole left paramedian pons.