Authors: DR HIMANSHU GUL MIRANI

Abstract

Background: Aphasia without accompanying motor deficit is an uncommon neurological presentation that may lead to diagnostic delay in emergency settings. Global aphasia without hemiparesis presents a particular challenge, as it may mimic seizure, metabolic encephalopathy, or postictal states, especially when early neuroimaging is unrevealing.

Case Presentation: An 84-year-old man with a background of asthma was brought to the emergency department following a witnessed episode of vacant staring with possible brief limb movements lasting approximately one minute. There was no loss of continence, tongue biting, prodromal symptoms, or aura. He had been well earlier that day, with no history of alcohol misuse, recent trauma, infection, or anticoagulant use. Following the episode, the patient demonstrated complete absence of meaningful speech despite preserved limb strength. This deficit was observed by paramedics and persisted on arrival to hospital one hour after symptom onset. He was hemodynamically stable with a regular cardiac rhythm. Neurological examination showed reduced environmental awareness with spontaneous eye opening. He produced incomprehensible vocalizations but localized pain in all four limbs. There was no facial asymmetry, and plantar responses were flexor bilaterally.

Investigations: Electrocardiography demonstrated sinus rhythm with left axis deviation. Blood tests revealed mild hyponatremia at 127 mEq/L and blood glucose of 10 mmol/L, with normal pH and lactate. Non-contrast CT brain imaging showed no acute intracranial abnormality.

Management and Outcome: The patient was admitted under stroke services and treated with loading-dose aspirin. MRI brain imaging subsequently demonstrated an acute left thalamic infarct. Carotid Doppler studies revealed less than 30 percent stenosis bilaterally. During inpatient monitoring, language function improved progressively, with full recovery of speech output and comprehension. He was discharged on clopidogrel for secondary stroke prevention.

Conclusion:
This case illustrates an atypical presentation of acute ischemic stroke manifesting as isolated global aphasia without motor deficit due to a strategic thalamic lesion. It highlights the limitations of early CT imaging and reinforces the importance of MRI diffusion-weighted imaging in patients presenting with isolated language impairment. Early recognition of this stroke phenotype is essential to avoid misdiagnosis and ensure timely secondary prevention.

Keywords: Stroke Emergency Department GAWH aphasia