Objective of this poster is to discuss a unique case of acute ischemic stroke presentation as spasticity of the affected side.

Hemiparesis after ischemic stroke is a common presentation, but spasticity presenting as an acute sign of cortical ischemic stroke is a rare phenomenon. Spasticity usually develops weeks after the stroke but not acutely.

67 year old African American male with past medical history of hypertension presented to ED with 3 hours history of left upper (LUE) and left lower extremity (LLE) weakness with stiffness. On examination NIHSS of 3 (1 LUE drift, 1 LLE drift, 1 for ataxia LUE) was given. Interestingly, patient had moderate to severe spasticity of LUE and LLE. CTH was unremarkable. CTA showed occlusion of right Anterior cerebral artery (ACA) A2 segment. After obtaining consent, tissue plasminogen activator was given. MRI brain was done that showed acute ischemic infarct involving the right ACA and right ACA- MCA (middle cerebral artery) watershed area of the cortex.

Spasticity is defined as a velocity dependent increase in muscle tone due to increased excitability of the muscle stretch reflex. In the cortex, frontal area contributes in the pyramidal pathway, premotor and supplementary motor cortices participates in sequencing, modulation of all voluntary movements and anterior cingulate cortex acts as cortical suppressant. These areas play an important role in muscle tone and activity. Disruption to these areas due to stroke or injury could lead to disruption of inhibitory projections to lower motor neurons with resultant spasticity.