Sudden Onset Focal Neurology: A Cardiac Cause

An 86 year-old female presented acutely to the regional stroke centre with aphasia and right-sided weakness. In the department, her neurology fluctuated, including aphasia, pupillary dilation on the left and variable right-sided weakness. MRI, CT head and CT angiography did not demonstrate any acute intracranial cause for her neurological presentation. She had multiple episodes of symptomatic third degree atrioventricular block with ventricular standstill, followed by short episodes of self-resolving atrial fibrillation. She was treated with isoprenaline and transferred to the tertiary cardiology centre for urgent pacing. Her neurological presentation was felt to be secondary to bradycardia-related cerebral hypoperfusion resulting in transient neurological sequelae. Stroke clinicians should be aware of this potentially under-reported stroke mimic, as atrioventricular block with loss of cardiac output is a class I indication for emergency pacing.