A 70-year-old woman, with a history of hypertension and poor compliance with medications, presented with 2 episodes of neurological dysfunction. During the first episode that occurred 2 years previously, she developed the sudden onset of non-fluent speech with associated anomia, impaired repetition of sentences, and preserved verbal comprehension and transient right hemiparesis. Her speech problems improved significantly over the subsequent days. In the recent/second episode, her troublesome symptoms included mutism, dysphagia (with brisk gag reflex bilaterally and preserved cough reflex), drooling of saliva, and difficulty in chewing and bilateral lingual paresis without tongue wasting. The jaw jerk was not brisk. When angry, she was able to produce words and short phrases. However, she did not produce any verbal output volitionally or in response to questions. There was no pseudobulbar affect or emotional incontinence during the period of her hospital stay. She was fully ambulant without any significant arm/leg weakness. Electrocardiogram and echocardiography were unremarkable. A CT angiogram of neck and intracranial arteries revealed only minimal atherosclerotic changes. Her recent cranial CT is shown in Figure 1.

A 70-year-old woman, with a history of hypertension and poor compliance with medications, presented with 2 episodes of neurological dysfunction. During the first episode that occurred 2 years previously, she developed the sudden onset of non-fluent speech with associated anomia, impaired repetitio...