Local(eyes)ing signs in sequential bihemispheric strokes

INTRODUCTION:: Decerebrate posturing typically occurs in the setting of midbrain injury. However, it may also be seen as the result of massive bilateral forebrain lesions. The latter localization is supported when seen concomitantly with roving eye movements and normal brainstem reflexes. CASE REPORT:: A 61-year-old woman developed aphasia and right hemiparesis and was found to have a left anterior middle cerebral artery stroke from atrial fibrillation. The following day, her examination quickly deteriorated from mild aphasia and right hemiparesis to coma, right gaze preference alternating with roving eye movements, and decerebrate posturing. Electroencephalography showed bihemispheric dysfunction, and magnetic resonance imaging showed new scattered right middle cerebral artery territory infarcts. She was found to have right A1 and M1 occlusions, and recanalization was achieved with intra-arterial tissue plasminogen activator. CONCLUSIONS:: This case highlights the localizing value of the constellation of coma, a gaze preference alternating with roving eye movements, and decerebrate posturing through a discussion of the relevant neuroanatomy and pathophysiology.