Recurrent supratentorial stroke with ipsilateral hemiplegia

Ipsilateral hemiplegia in hemispheric stroke is uncommon in clinical practice, and its pathophysiological mechanism remains partially understood. We report a rare case of right hemiplegia following a right supratentorial stroke, with emphasis on the underlying mechanistic hypotheses and their clinical implications. A 68-year-old woman with a history of hypertension, congenital microphthalmia, and left pontine ischemic stroke 3 years earlier presented with acute altered consciousness and deterioration of her right-sided motor deficit. Neuroimaging (brain computed tomography scan and magnetic resonance imaging) revealed right supratentorial infarcts, including a subacute infarct in the superficial territory of the right middle cerebral artery and an acute infarct in the deep territory of the right anterior cerebral artery without any recent contralateral lesions. Forty-three similar cases have been reported, with post-stroke functional reorganization and congenital anomalies of corticospinal tract decussation commonly cited as main mechanisms. This atypical presentation should be recognized in both the acute phase, when urgent therapeutic decisions must be made, and the chronic phase, when rehabilitation should be adapted to optimize functional recovery.