Bilateral Anterior Cerebral Artery Strokes

Some Embolic strokes of undetermined origin (ESUS) are extremely rare. That is the case of a patient with multiple vascular risk factors who presented with persistent inability to get up after a fall at home. Physical examination revealed only mild left-sided claudication. Magnetic resonance imaging showed multiple paramedian emboli in both cerebral hemispheres, with normal cardiac tests (echocardiogram; Holter ECG).

Finally, a CT angiogram revealed a high grade stenosis of an azygos anterior cerebral artery. The patient had a prothrombotic state due to poorly controlled vascular risk factors and very low vitamin B12 levels.

Image source: 

https://www.neuroradiologycases.com/2012/04/azygus-aca.html

The importance of gait and steadiness assessment

 

In patients presenting with acute or subacute neurological deterioration, the physical examination may be nonspecific, being essential, whenever it is possible, to assess their steadiness and gait, independently or with assistance. 

Gait and steadiness are a highly complex functions requiring the precise synchronization of numerous neural pathways. Therefore, when the brain exhibits diffuse impairment, as in delirium, or when one of these pathways is damaged, as in a mild stroke, both will be affected and, sometimes, will be the only clue in the entire clinical examination to guide the investigation.

Source: “Figure - PMC.” Nih.gov, 2016, pmc.ncbi.nlm.nih.gov/articles/PMC5318488/figure/Fig1/. Accessed 8 Dec. 2025.