Please improve this case report and add relevant references: Isolated Case of Alexia Following Cardiac Ablation: A Rare Stroke Presentation
Abstract
This case report presents a 68-year-old male exhibiting isolated alexia, an unusual inability to comprehend written language, following a cardiac ablation procedure. Prompted by this unique symptom, the patient underwent a comprehensive evaluation in the Emergency Department. Neurological assessment, utilizing the NIH Stroke Scale, revealed alexia and aphasia characterized by fragmentary expression. Imaging studies, including CT and MRI scans, discovered an acute left PCA territory infarct.
The absence of typical visual, motor, or sensory deficits challenges traditional diagnostic expectations, emphasizing the necessity for a multidisciplinary approach and vigilant post-procedural care. This case highlights the importance of nuanced diagnostic assessments in patients at high risk of embolic events, emphasizing the need for diverse manifestations of recognition for optimal patient care.
Introduction
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This patient's unique struggle with alexia challenges traditional diagnostic expectations in potential stroke patients. Understanding and recognizing such nuanced presentations are crucial for clinicians, expanding their awareness in quickly assessing potential stroke patients.
Case Presentation

A 68-year-old male with a medical history significant for hypertension, congestive heart failure, and atrial fibrillation faced an unexpected challenge following discharge from a cardiac ablation procedure—difficulty understanding the instructions on his new prescription medications. He spoke with nursing staff and reported that he was unable to read the individual words or understand their meaning. Given his recent discharge, nursing staff asked that he visit the Emergency Department (ED) for further assessment.
Upon presentation to the ED, the patient was found to have persistent alexia and progressive difficulty with word-finding. On detailed neurological examination, both pupils were equal, round, and reactive to light. Extraocular eye movements were full, with no nystagmus. Notably, there were no overt visual field defects, motor deficits, or sensory abnormalities. Given his history of atrial fibrillation and recent discharge, concern for a neurological event was triggered.
To further evaluate the neurological presentation, the NIH Stroke Scale was employed. The assessment revealed aphasia, specifically marked by fragmentary expression and the need for inference (item 9). This highlighted the isolated language disturbance as the primary neurological deficit. 
An initial CT scan from the ED showed a confluent area of hypodensity in the left occipital and mesial temporal lobes, indicative of an acute PCA territory infarct. There was no hemorrhagic transformation, mass effect, or midline shift observed, suggesting a contained ischemic event. Unfortunately, the patient was beyond the recommended time window for intravenous thrombolysis. The patient was then admitted to the hospital for further assessment and management.
Following admission to the hospital, an MRI scan confirmed the acute infarction with restricted diffusion in the posterior left temporal and left occipital lobes. Suspected petechial hemorrhagic transformation was noted in the left occipital lobe. There were no additional findings and the patient was discharged a few days after in an improved condition.
Discussion
This unique case brings attention to the uncommon manifestation of isolated alexia as the sole neurological deficit of an acute stroke. Unlike typical stroke presentations, the absence of additional visual, motor, or sensory impairments challenges traditional diagnostic expectations. The severity of aphasia, as assessed by the NIH Stroke Scale, underscores the substantial impact on language processing, necessitating a nuanced approach to understanding the underlying neurologic etiology.
A deeper exploration into aphasia is essential for elucidating the diverse language deficits observed in stroke patients. Aphasia, a language disorder resulting from damage to specific brain areas responsible for language processing, manifests in various types. Understanding these types aids in elucidating the neurologic etiology:
Broca's Aphasia (Non-fluent Aphasia):
Lesion Location: Left frontal lobe, typically Broca's area.
Characteristics: Reduced fluency, difficulty forming grammatically complex sentences, preserved comprehension.
Wernicke's Aphasia (Fluent Aphasia):
Lesion Location: Left temporal lobe, Wernicke's area.
Characteristics: Fluent but nonsensical speech, impaired comprehension, poor word selection
Global Aphasia:
Lesion Location: Extensive damage to language areas.
Characteristics: Severe impairment in both expressive and receptive language skills
Conduction Aphasia:
Lesion Location: Arcuate fasciculus, connecting Broca's and Wernicke's areas.
Characteristics: Fluent speech with paraphasic errors, difficulty repeating phrases.
The neurologic etiology of isolated alexia can be multifaceted. In the context of cardiac ablation, potential mechanisms include embolic events, vascular compromise, or cerebral hypoperfusion during the procedure. Additional diagnoses to consider may be migraine aura, traumatic brain injury, brain tumor, neurodegenerative disorders (e.g, Alzheimer’s Disease), conversion disorder, medication-induced cognitive impairment, among others. The unique nature of alexia, without broader neurological sequelae, prompts consideration of specific cortical regions associated with language processing.
This case underscores the necessity of vigilant post-procedural care, recognizing that neurological manifestations may extend beyond conventional parameters. Healthcare providers should consider tailored assessments for language function, especially in individuals with elevated embolic risk.
Conclusion
The isolated manifestation of alexia without motor deficits serves as a reminder of the diverse ways in which strokes can present, requiring a nuanced diagnostic approach. This case contributes to the evolving understanding of neurological complications post-cardiac procedures and underscores the need for continued research and awareness in this domain.