Paraplegia of cortical origin: case report

Abstract

Introduction. The irrigation of the central nervous system (CNS) comes from the Polygon of Willis (PW), existing several variations in its distribution called anatomical variations. Objective. A case report of paraplegia of central origin due to an anatomical variation in the PW. Report. A 78 years-old woman with a fall from her height followed by weakness in the lower limbs (LLLL) and right upper limb (RULL). She had right nasolabial sulcus erasure, asymmetrical crural flaccid paraplegia, worse to the left, flaccid monoplegia of the RUL, hypoesthesia in the LLLL, and bilateral Babinski sign. Cervical and dorsal spine CT scans ruled out traumatic causes. Skull CT showed left frontoparietal hypodensity, suggesting recent ischemia. Further investigation with echocardiogram and Doppler ultrasound of carotid and vertebral arteries were normal. Skull MRI with signs of recent infarction in the left cingulate and superior frontal gyrus and minimal cortico-subcortical ischemic foci in the right superior frontal gyrus, with agenesis of the A1 portion of the right anterior cerebral artery on angioresonance. Results. The most prevalent CNS disease is CVAi, whose symptoms depend on the affected brain region. The atypical presentation reported was due to an anatomical variation in PW, the agenesis of portion A1 of the right anterior cerebral artery. The prevalence of anatomical variations in the PW is about 68.22%, with the posterior communicating artery being the most affected segment. Conclusion. Most anatomical variations of cerebral arterial circulation do not generate clinical repercussions because they are generally not pathological. However, it is important to know them to make the differential diagnosis in atypical cases and minimize surgical iatrogenesis.