Case Presentation: An 85-year-old male with a history of untreated hypertension, on aspirin, presented to the emergency department with transient right upper and lower extremity weakness. Upon presentation the National Institutes of Health (NIH) Stroke Scale was 0. Symptoms had started three days prior with right leg weakness which resolved after a few minutes of rest, with recurrence the following day, also lasting a few minutes. Patient reported no dysphagia, dysarthria, diplopia, or dysesthesia. The following day, right arm weakness returned, but had resolved once again upon arrival to the ED. Blood pressure: 205/64 which precipitously dropped to 132/62 without intervention. Computed tomography (CT) head without contrast showed no evidence for acute intracranial hemorrhage or infarction. Echocardiogram was negative for thrombi and CT angiography neck unremarkable for significant stenosis. Patient was loaded with aspirin 325 mg and clopidogrel 300 mg on day one of hospitalization. Tissue plasminogen activator was not given as patient was outside window of opportunity. Permissive hypertension was allowed for the first 48 hours. This presentation of right-sided hemiparesis continued interspersed with periods of remission, in a stuttering fashion. The acute hemiparesis resulted in several stroke alerts, only to have the weakness improve rapidly. Repeat NIH score ranged from 1 to 4. Magnetic resonance imaging (MRI) brain showed a non-hemorrhagic acute/subacute left putaminal and another smaller high frontal cortical infract, both in the left MCA territory. On day four of hospitalization, the patient’s left-sided weakness became persistent, with evidence of subacute infarct in the left periventricular white matter extending to the lentiform nucleus on repeat CT scan. The patient was discharged on DAPT and high dose statin.

Discussion: Stuttering lacunar stroke can be difficult to diagnose and treat given the episodes of rapidly improving symptoms. Healthcare providers should be aware lacunar strokes can present in a stuttering time course, which can prompt early initiation of therapy (DAPT or tPA) or advanced imaging. Although management is similar to typical ischemic strokes with DAPT, statins, blood pressure control, and rehab, many repeat CT imaging may be required until symptoms stabilize to rule out hemorrhagic conversion, given sudden worsening of symptoms.

Conclusions: A subset of lacunar strokes may present in an atypical ‘stuttering’ fashion, in which symptoms exhibit periods of transient improvement in between gross neurologic deficits, making diagnosis difficult and management challenging. Healthcare providers should be aware about this presentation given it can trigger multiple stroke alerts with a high risk of developing a completed stroke.