Stroke of the Right Supraclinoid ICA and Bilateral Numbness

Neuroanatomical Basis for Stroke Symptoms

The American Heart Association guidelines indicate that symptoms of stroke in the distribution of the right internal carotid artery include left-sided weakness, left-sided sensory loss, and other left-sided deficits 1
Strokes affecting the right internal carotid artery territory classically cause left-sided sensory and motor deficits due to the crossing of neural pathways 1
The classic presentation of stroke includes contralateral hemiparesis and sensory deficits affecting the face, arm, and/or leg 1

Pre-existing contralateral sensory deficits from a previous stroke may contribute to bilateral symptoms 2
Bilateral watershed infarctions in a patient with severe carotid disease and systemic hypoperfusion can cause bilateral numbness 3
Concurrent vertebrobasilar insufficiency affecting sensory pathways bilaterally may result in bilateral symptoms 4
Non-stroke etiology for the bilateral symptoms, such as peripheral neuropathy or spinal cord pathology, should be considered 2

Brain MRI with diffusion-weighted imaging can identify the location and extent of infarction in patients with suspected right supraclinoid ICA stroke 4
Vascular imaging (CTA or MRA) can evaluate for occlusions or stenoses in multiple vascular territories 2
Transcranial Doppler can assess flow velocities and detect potential collateral circulation patterns 5
Evaluation for cardiac sources of emboli that could cause multiple territory strokes is important 2
Assessing for systemic conditions that could cause global hypoperfusion is crucial 3

Bilateral symptoms in the setting of unilateral ICA stroke should raise suspicion for an alternative or additional diagnosis 2
The presence of bilateral symptoms does not exclude a diagnosis of stroke but makes a single unilateral supraclinoid ICA stroke unlikely as the sole cause 1
Careful assessment of collateral circulation is important as it may influence both symptoms and outcomes 5
Considering the possibility of concurrent small vessel disease or other stroke mechanisms is essential if symptoms don't match the expected vascular territory 2