Pontine warning syndrome

Arch Neurol. 2008 Oct;65(10):1375-7. doi: 10.1001/archneur.65.10.1375.


Background: Little is known about stroke mechanisms in patients with fluctuating symptoms and the role of branch atherosclerotic disease.

Objective: To report a novel stroke presentation associated with a paramedian pontine infarct due to branch disease with a fluctuating course.

Design: Case report.

Setting: Academic research. Patient A 63-year-old man with hypertension, diabetes mellitus, and dyslipidemia was seen with fluctuating right-sided weakness and dysarthria. He had had 2 episodes of complete bilateral horizontal conjugate gaze palsy with unimpaired consciousness lasting for 5 minutes each. His pupils were 4 mm and were equal and reactive to light. Vertical gaze and convergence were preserved. His neurologic status fluctuated between 3 and 15 on the National Institutes of Health Stroke Scale.

Main outcome measures: Results of computed tomographic angiography, perfusion, and magnetic resonance imaging.

Results: Intravenous tissue plasminogen activator was administered within a 3-hour window. Fluctuations in motor weakness persisted for 12 hours after receiving thrombolytic therapy. Neuroimaging showed an acute left paramedian pontine infarct with a patent basilar artery.

Conclusions: Branch disease is a common mechanism in pontine infarctions. We coined the term "pontine warning syndrome" to characterize recurrent stereotyped episodes of motor or sensory dysfunction, dysarthria, or ophthalmoplegia associated with a high risk of imminent basilar artery branch infarction and a permanent deficit resembling those of capsular warning syndrome.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Basilar Artery / pathology
  • Basilar Artery / physiopathology
  • Brain Stem Infarctions / diagnosis*
  • Brain Stem Infarctions / pathology
  • Brain Stem Infarctions / physiopathology
  • Dysarthria / etiology
  • Dysarthria / physiopathology
  • Humans
  • Ischemic Attack, Transient / diagnosis*
  • Ischemic Attack, Transient / pathology
  • Ischemic Attack, Transient / physiopathology
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Movement Disorders / etiology*
  • Movement Disorders / physiopathology
  • Ocular Motility Disorders / etiology*
  • Ocular Motility Disorders / physiopathology
  • Paresis / etiology
  • Paresis / physiopathology
  • Pons / blood supply*
  • Pons / pathology
  • Pons / physiopathology
  • Predictive Value of Tests
  • Prognosis
  • Tomography, X-Ray Computed
  • Vertebrobasilar Insufficiency / diagnosis*
  • Vertebrobasilar Insufficiency / pathology
  • Vertebrobasilar Insufficiency / physiopathology