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A Tetrad Cognitive Presentation of Gerstmann Syndrome: A Rare Manifestation of Stroke

Case report

Abstrak

Sindrom Gerstmann merupakan gejala neurologi yang jarang berlaku akibat kecederaan di bahagian otak kiri yang dominan dan tanda-tanda gejala ini adalah agrafia, akalkulia, jari agnosia serta disorientasi kiri-kanan. Kami ingin melaporkan kes melibatkan pesakit berumur 52 tahun lelaki, dengan dominan tangan kanan yang datang ke Jabatan Kecemasan dengan keadaan kekeliruan selama sehari. Beliau tidak mengenali masa, tempat dan orang. Hasil pemeriksaan tertumpu kepada sistem neurologi mendapati beliau mempunyai tanda strok atipikal iaitu tanda-tanda Sindrom Gerstmann. Oleh yang demikian, protokol strok telah diaktifkan dan pesakit telah menjalani ujian imbasan otak. Keputusan imbasan otak menunjukkan kawasan penumbra yang besar di bahagian 'left middle cerebral artery' teritori. Manakala, ujian susulan 'computed tomography' angiogram mendapati terdapatnya thrombus (darah beku) yang panjang di saluran 'left internal carotid artery'. Prosedur trombektomi tidak dapat diteruskan kerana terdapatnya trombus yang keras. Seterusnya  beliau dirawat mengunakan rawatan anti-platlet. Beliau telah dibenarkan keluar dari hospital setelah tiga hari dan diberikan rawatan susulan sebagai pesakiy luar. Jadi, kami ingin menekankan betapa pentingnya mengenalpasti gejala Sindrom Gerstman sebagai salah satu tanda strok akut yang tidak tipikal.

Abstract

Gerstmann Syndrome is a rare neurological presentation due to a lesion in the left dominant parietal lobe, manifesting as a tetrad of agraphia, acalculia, finger agnosia and right-left disorientation. We present a case of a 52-year-old man, right hand dominant, who presented to the Emergency Department with acute confusion for one day. He was disorientated to time, place and person. Focused neurological examination revealed atypical signs of acute stroke, comprising agraphia, acalculia, finger agnosia and right-left disorientation. Stroke protocol was activated and he underwent computed tomography brain perfusion, which confirmed a large penumbra area at the left middle cerebral artery territory. Computed tomography angiogram of the carotid arteries showed a long segment thrombosis in the left internal carotid artery. Emergency thrombectomy was abandoned due to impenetrable hard thrombus. He was treated with dual antiplatelet therapy and discharged after three days with partial improvement in terms of following commands, simple calculations and reduced finger agnosia. He was scheduled for outpatient follow up. This case highlights Gerstmann syndrome as an atypical manifestation of acute stroke.