Classical locked-in syndrome secondary to acute bilateral pontine infarction in a low-resource emergency setting: a case report

Abstract Background Locked-in syndrome (LIS) is a rare neurological disorder characterized by complete paralysis with preserved consciousness. Early recognition is critical, to facilitate prompt stroke evaluation and timely reperfusion therapy in eligible patients. Magnetic resonance imaging (MRI), particularly when initial computed tomography (CT) findings are inconclusive, plays an important role in confirming the diagnosis of brainstem infarction. Case presentation We report a 60-year-old Black African woman from Ethiopia who presented with sudden quadriplegia, anarthria, and preserved vertical eye movements. She presented approximately two days after she was last known to be neurologically normal, which precluded eligibility for intravenous (IV) thrombolysis. Because vascular imaging was not performed, eligibility for endovascular therapy could not be assessed. Initial CT imaging did not provide definitive evidence of acute brainstem infarction, whereas MRI revealed acute bilateral pontine and right cerebellar infarcts, confirming the diagnosis of classical LIS. A lack of stroke and intensive care unit (ICU) resources limited management options. Supportive care, early multidisciplinary involvement, and structured family counselling were provided to optimize patient outcomes. Despite these measures, the patient developed aspiration pneumonia and succumbed to cardiorespiratory failure on day 10 of hospitalization. Conclusion This case underscores the diagnostic and management difficulties associated with LIS, especially in resource-limited environments. Although MRI was essential for confirming the diagnosis after non-diagnostic CT imaging, timely access to reperfusion therapy and appropriate critical care support is important in eligible patients with acute posterior circulation ischemic stroke. In this patient, delayed presentation precluded IV thrombolysis and likely contributed to the poor clinical outcome, while the absence of vascular imaging prevented assessment of eligibility for endovascular therapy. Strengthening stroke systems of care, including public awareness, rapid referral pathways, access to reperfusion therapies, and intensive care capacity, is essential to improve survival and functional recovery in resource-limited settings.