Anodal Transcranial Direct Current Stimulation as an Adjunct to Physiotherapy in Lacunar Stroke

Lacunar strokes affecting deep subcortical motor pathways often lead to significant disability despite their small lesion size, and recovery can remain incomplete with physiotherapy alone. Transcranial direct current stimulation (tDCS) has emerged as an accessible neuromodulation tool that may enhance post-stroke rehabilitation, though evidence from resource-limited settings in India is sparse. This case report describes a 56-year-old man with hypertension and type 2 diabetes mellitus who developed acute left-sided weakness, imbalance, and mild facial asymmetry, with CT imaging confirming a right-sided lacunar infarct involving the basal ganglia and corona radiata. At admission for rehabilitation at All India Institute of Medical Sciences (AIIMS), Deoghar, Jharkhand, India, he presented with moderate to severe motor impairment (Fugl-Meyer Assessment (FMA) score: upper extremity (UE) 21/66, lower extremity (LE) 11/34) and mild cognitive deficits (Montreal Cognitive Assessment (MoCA) score: 16/30). He underwent a six-week program that integrated anodal tDCS (2 mA for 20 minutes, five days per week), delivered over the ipsilesional primary motor cortex using a Neurostim device (Neurosoft LLC, Ivanovi, Russia), combined with physical physiotherapy. By week 4, he demonstrated improved proximal limb control and sitting balance; by week 6, he achieved supported standing, initiated assisted steps, and showed meaningful improvements in hand function. Post-intervention scores increased to UE 34 and LE 20 on the FMA score and 20 on the MoCA score. At the three-month follow-up, these motor gains were sustained, while cognitive scores remained stable. No adverse effects were reported. This case highlights the feasibility, safety, and potential clinical value of combining tDCS with physiotherapy to support motor recovery and cognitive stability in lacunar stroke, particularly in rural tertiary-care environments with limited rehabilitation resources. Larger controlled studies are needed to refine stimulation parameters, identify responders, and strengthen the evidence base for tDCS in small-vessel ischemic stroke.