The pons contains numerous critical pathways and even small infarcts often result in significant neurological deficits. Pontine infarcts have a wide spectrum of clinical manifestations including classical syndrome of ‘crossed’ face and body findings, to less common presentations such as pure hemiparesis, pure sensory stroke, locked-in syndrome and coma. We present the case of a sizeable infarct affecting approximately 50% of the right pons that resulted in no residual neurological deficits within 3 days of hospitalization. This case calls for a measured approach to prognostication in pontine strokes as not one size fits all.

A 53-year-old woman with hypertension and diabetes mellitus type-II presented with a 1-week history of generalized weakness, gait instability, slurred speech, and tingling in the lower extremities that gradually ascended to the upper extremities and face. Physical examination demonstrated no focal weakness, hypoesthesia, or other neurological deficits. Cranial nerve examination was unremarkable. Brain MRI demonstrated a large acute infarct in the right pons and tiny chronic infarcts in the left supratentorial white matter. Bickerstaff and CLIPPERS were considered on the differential but ruled out considering lack of contrast enhancement on gadolinium-enhanced imaging. Despite the size and location of the infarct, the patient did not exhibit any residual neurologic symptoms. Her blood pressure control was optimized prior to her discharge home.

This case highlights the rare occurrence of a large pontine acute infarct involving approximately 50% of the right pons in a patient without residual neurological deficits within less than 10 days of symptom occurrence. While the prognosis of pontine stroke varies depending on the location and extent of the infarct, it is highly unusual for a stroke of this size to leave no neurological deficits – not only with respect to brainstem nuclei but to long tracts including the medial lemniscus and corticospinal systems.