(Kiosk 3) Characterization of Unexpected Cognitive and Affective Changes After Iatrogenic Posterior Circulation Strokes: A Case Report

Case Diagnosis: A 35-year-old female with a history of recurrent arteriovenous malformations (AVMs) who underwent microbead embolization of a left subclavian AVM leading to multifocal iatrogenic strokes in the posterior circulation causing unexpected deficits in cognition and affect.

Case Description or Program Description: MRI brain demonstrated extensive infarcts of the bilateral thalami, midbrain, pons, cerebellum, occipital and inferomedial temporal lobes. The suspected etiology was microbead movement from the AVM to the left vertebral artery, and into the posterior cerebral circulation. The patient was stabilized in the neuro-intensive care unit and admitted to acute inpatient rehabilitation. At initial evaluation, she was noted to have severe impairments in executive, visual-spatial, and linguistic function as well as significant disinhibition of thoughts. She had profound placidity and visual agnosia, as well as mild hypersexuality and hyperorality.

Setting: Tertiary adult rehabilitation center

Assessment/Results: Given this constellation of symptoms, a clinical diagnosis of cerebellar cognitive affective syndrome (CCAS) versus Kluver-Bucy syndrome was made. Inattention was targeted with a neurostimulant regimen with notable improvement.

Discussion (relevance): This case demonstrates cognitive and affect changes in a patient with multifocal infarcts primarily in the posterior circulation..Such deficits are classically attributed to damage to the frontal lobe, however there is growing evidence that structures in the posterior fossa such as the cerebellum and inferomedial temporal lobes play an important role in cognitive functioning. Abnormalities in these areas have even been related to the development of schizophrenia. In this case report, we review the diagnoses of cerebellar cognitive affect syndrome (CCAS) and Kluver-Bucy syndrome as possible explanations for these unexpected cognitive changes.

Conclusions: The connection between the posterior cerebrum and cerebellum with cognitive function is not fully elucidated, but evidence of its importance is growing. It is important for Neurorehabilitation specialists to understand this connection for proper diagnosis, prognostication, and treatment in these types of brain injuries.