Benedict hand, a claw like appearance with hyperextension at the metacarpophalangeal (MCP) joints and flexion of the proximal and distal interphalangeal (IP) joints, is typically seen in ulnar neuropathy. We are presenting a case of stroke manifesting with Benedict hand mimicking ulnar neuropathy.

A 68-year-old woman with hypertension, diabetes and multiple lacunar strokes presented with sudden-onset weakness of her entire right arm briefly (which got improved in few minutes), followed by persistent weakness of right medial three digits (3, 4 and 5). On exam, right upper extremity was found in Benedict’s position, flexor carpi ulnaris 4/5, flexor carpi radialis 4+/5, palmar and dorsal interrosei 1/5, abductor digiti minimi 0/5, first and second lumbricals 4+/5, third and fourth lumbricals 1/5, abductor pollicis brevis 5/5, flexor digitorum profundus first and second 4+/5, flexor digitorum profundus third and fourth 1/5 and flexor digitorum superficialis 4/5. The rest of the neurological exam was unremarkable including negative tinels at elbow. MRI showed small acute infarct within left precentral gyrus.

This is a rare presentation of acute ischemic stroke as pseudo-ulnar nerve palsy. It is usually misdiagnosed as peripheral neuropathy. Therefore, ischemic stroke can be considered as one of the differential diagnosis for acute mononeuropathy in the setting of vascular risk factors and clinical course. The key to our case is initial complaint of transient entire right arm weakness that settled down into purely ulnar palsy signs. This reiterates the importance of chronology in history taking. Imaging study might be a tool to lead to the prompt diagnosis.