Disproportionate bulbar dysfunction following small corona radiata infarction in vascular parkinsonism

Rationale: Subcortical lacunar infarctions commonly occur in cerebral small vessel disease and contribute to progressive functional decline in older adults. Infarction of the corona radiata may disrupt converging corticobulbar pathways. In patients with vascular parkinsonism, diminished subcortical motor reserve may render bulbar function particularly vulnerable, resulting in neurological deficits disproportionate to lesion size. Patient concerns: A 75-year-old woman with vascular parkinsonism presented with acute dysarthria, severe dysphagia requiring nasogastric tube feeding, and marked gait instability. Diagnoses: Brain magnetic resonance imaging demonstrated a small acute infarction in the left corona radiata superimposed on extensive cerebral small vessel disease. Despite the limited infarct size, she developed profound swallowing dysfunction and impaired mobility. Interventions: Early multidisciplinary rehabilitation, including speech-language therapy, graded diet advancement, and balance-oriented gait training, was initiated and maintained throughout the 3-month follow-up period. Outcomes: At the 3-month follow-up, the patient demonstrated meaningful functional recovery, with the Barthel Index improving from 35 to 75, the Functional Ambulation Category improving from 1 to 4, and the Dysphagia Outcome and Severity Scale improving from level 2 to level 6, allowing removal of the nasogastric tube and resumption of safe oral intake. Lessons: Even small corona radiata infarctions may cause disproportionately severe bulbar dysfunction in patients with vascular parkinsonism and extensive cerebral small vessel disease. Early multidisciplinary rehabilitation was associated with meaningful functional recovery despite diminished subcortical motor reserve.