A rare coincidence of upper extremity pure motor monoparesis due to stroke during thoracic surgery
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LETTER TO THE EDITOR
A rare coincidence of upper extremity pure motor monoparesis due to stroke during thoracic surgery Ivana Jurjević1,2 · Hrvoje Bilić1 · Ivan Jovanović3 · Dinko Stančić‑Rokotov2,4 Received: 24 October 2019 / Accepted: 21 February 2020 © Belgian Neurological Society 2020
Dear Editor, Isolated upper extremity motor monoparesis is a wellknown, but rare stroke manifestation. It is often mistaken for other causes of weakness, mostly peripheral nerve pathology [1–4]. When combined with long-lasting thoracic surgery, the first thing that comes to mind is a brachial plexus lesion [5]. We would like to present a case of a patient who suffered a stroke with pure motor right arm monoparesis during thoracic surgery. A 64-year-old man with previously known right lung adenocarcinoma was admitted to the Department of Thoracic Surgery due to cancer recurrence after initial right upper lobectomy. This time, he underwent a right thoracotomy with total right pulmectomy. The operation lasted for 5 h during which his right arm was lifted above his head, and it ended without complications. When he awoke from general anaesthesia in the intensive care unit, isolated right upper extremity weakness was noticed. He did not seem to have any other neurological deficits. His general medical history was negative for hypertension, diabetes and cardiac arrhythmias. His initial neurological evaluation showed pure motor weakness of the entire right upper extremity (manual muscle testing 1/5), normal speech, no cranial nerve lesions, no sensory deficits and no weakness in other extremities. Deep tendon reflexes were symmetrical, except for a slightly
* Ivana Jurjević [email protected] 1
Department of Neurology, Clinical Hospital Centre Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia
2
School of Medicine, University of Zagreb, Šalata 2, 10000 Zagreb, Croatia
3
Department of Radiology, Clinical Hospital Centre Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia
4
Department of Thoracic Surgery, Clinical Hospital Centre Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia
diminished right m. brachioradialis reflex. Babinski sign was negative bilaterally. An emergency brain computed tomography showed no pathology, and it was presumed that the isolated weakness of the upper right extremity was a consequence of brachial plexus injury due to long-lasting straining during arm elevation. After 5 days, electromyography (EMG) and nerve conduction study (NCS) of the upper extremities were done, together with neurological re-evaluation. The patient showed no changes compared to the initial status. EMG showed no signs of spontaneous or intentional activity in the analysed muscles of the right upper extremity due to flaccid paresis, with NCS (bilateral median, ulnar, radial, axillary, musculocutaneous and suprascapular nerve testing) within the normal range. On the tenth day following surgery, a brain magnetic resonance imaging (MRI) was done, showing areas of early subacute ischaemia in the perirolandic region, deep vascular territo
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