Disclosures: Tope Adedolapo, Medical Student: No financial relationships or conflicts of interest

Case Diagnosis: Apraxic Agraphia secondary to acute ischemic stroke.

Case Description: 61-year-old left-handed male presented to the emergency department with bilateral lower extremity weakness. Imaging revealed acute left anterior cerebral artery and pontine infarcts. Patient was not a candidate for tissue plasminogen activator therapy or thrombectomy. Following acute care hospitalization, patient was recommended for acute inpatient rehabilitation. On presentation he was found to have a mild cognitive communication impairment. Patient had intact reading and oral spelling, however when prompted to write the same words to dictation, he had legible writing but notable difficulty with letter formation. Errors were characterized by letter substitution and production of numbers in place of letters. For example, when asked to write “pencil”, he wrote “91E01”; for “hammer”, he wrote “HAMM18”; and for “house”, he wrote “H0101”. Patient expressed good awareness of his errors and continued daily speech therapy to address communication deficits.

Setting: Acute Inpatient RehabilitationAssessment/

Results: Upon discharge, patient was able to independently write nine of ten, 1-3 syllable words. Two of these words he independently self-corrected. He will continue to work with speech therapy as an outpatient.

Discussion: It is not uncommon for patients with cerebrovascular accidents to have motor deficits manifesting as apraxic agraphia. However, this is a unique presentation characterized by legible writing, with errors of substituting numbers in place of letters. There is currently no consensus on which region of the brain when lesioned, can cause apraxic agraphia. Further research is needed to elucidate the mechanism of disease in apraxic agraphia.

Conclusion: Although a unique presentation to a common stroke type, this case highlights the importance of a comprehensive approach to the rehabilitation program. A holistic rehabilitation program can play a vital role in improving functional deficits in patients. Patient will continue with outpatient rehabilitation therapy with an emphasis on retraining letter formation with visual and tactile models.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/unique-presentation-of-apraxic-agraphia-following-left-anterior-cerebral-artery-and-pontine-ischemic-stroke-a-case-report/