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Neurological Rehabilitation

Acute left-sided weakness in inpatient rehabilitation: A clinical vignette

Friday, October 24, 2025
8:00 AM - 9:15 AM MT
Location: Kiosk 5
Has Audio

    Poster Presenter(s)

  • Carsen Cash, MD

    Resident Physician
    Vanderbilt University Medical Center PM&R Program
    Nashville, Tennessee

    • Co-Author(s)

  • AM

    Alexandra K. Miller, MD

    Resident Physician
    Vanderbilt University Medical Center PM&R Program
    Whites Creek, Tennessee

  • Jack E. Kilgore, III, MD

    Resident Physician
    Vanderbilt University Medical Center
    Nashville, Tennessee

  • VM

    Vartgez Mansourian, MD

    Attending Physician
    Vanderbilt University School of Medicine, Dept of PM&R
    Nashville, Tennessee

Disclosure(s):
Carsen Cash, MD: No financial relationships to disclose
Jack E. Kilgore, MD, III: No financial relationships to disclose
Case Diagnosis: The patient was diagnosed with a right lateral medullary stroke.

Case Description or Program Description: A 57-year-old woman presented to the emergency department with two days of left-sided weakness. Her physical exam was notable for left-sided weakness and sensory deficits, in addition to left sided ataxia. CTA showed stenosis in portions of the cerebral circulation but without occlusion. An MRI scan of the brain showed no evidence of intracranial abnormality or stroke. She was outside the treatment window for intervention and thus admitted to the hospital. She was diagnosed with functional neurologic disorder (FND) with a positive Hoover sign noted, and she was then transferred to inpatient rehabilitation.
Upon admission to inpatient rehabilitation, her exam was similar to the previous exam, but positive Hoffmann and Babinski signs on the left were found.

Setting: Inpatient Rehabilitation

Assessment/Results: The differential diagnosis included stroke as the top possibility, which could include anywhere from the right motor cortex and as caudal as the medulla. Functional neurologic disorder was also on the differential diagnosis, though lower due to presence of upper motor neuron findings. Repeat MRI eight days after symptom onset demonstrated a right medullary infarct.

Discussion (relevance): The physical exam did not match the admitting diagnosis of FND, and the workup continued until the diagnosis matched the clinical findings. As rehabilitation physicians, it is critical to perform an unbiased physical exam upon admission and frequently during hospitalization because symptoms can change or be missed. This can result in the patient starting secondary stroke prevention and receiving the appropriate individualized rehabilitation protocol.

Conclusions: This case discusses a patient with a lateral medullary stroke which was initially misdiagnosed as functional neurologic disorder. A thorough physical exam is critical to detecting subtle findings that could lead to a diagnosis, changing the patient’s course of treatment and rehabilitation.