Cortical Manifestations in Capsular Warning Syndrome: Expanding the Clinical Spectrum With a Case of Subcortical Aphasia

Capsular warning syndrome (CWS) is a form of transient ischemic attack characterized by repetitive episodes of sensorimotor deficits within 24 hours, typically involving subcortical ischemia of the internal capsule without cortical features. We report a case of a 75-year-old right-handed female who presented with fluctuating neurological deficits, including Broca's aphasia, right-sided hemiplegia, right central facial palsy, and right hemianesthesia. She experienced seven episodes of waxing and waning symptoms lasting from five minutes to an hour, with National Institutes of Health Stroke Scale (NIHSS) scores ranging from 0 to 17. Computed tomography (CT) was unremarkable, and she received intravenous recombinant tissue plasminogen activator (rTPA) four hours after the initial onset of symptoms, eventually resulting in the resolution of aphasia but with residual hemiplegia. Magnetic resonance imaging (MRI) performed 24 hours later revealed acute infarction of the left internal capsule, caudate nucleus, and lentiform nucleus. This case underscores the importance of recognizing atypical presentations of capsular warning syndrome in the emergency room, which may indicate reversible dysfunction that may respond to timely reperfusion therapy.