What the findings may mean

• Horizontal conjugate gaze palsy localizes most often to the pons, involving the abducens nucleus or paramedian pontine reticular formation. A lesion of the abducens nucleus prevents both eyes from looking toward the affected side.
• A midbrain infarct more commonly causes vertical gaze problems, third-nerve signs, unequal pupils, eyelid droop, or impaired adduction. So a tiny midbrain DWI lesion may be relevant, but it may not fully account for a horizontal gaze palsy.
• Slurred speech can arise from corticobulbar or cerebellar/brainstem involvement. Posterior-circulation ischemia can worsen unpredictably, particularly if there is vertebral or basilar artery disease.

Immediate treatment plan: hospital stroke protocol

1. Activate stroke/neurovascular team immediately. Record exact last-known-well time and serial NIHSS/brainstem examinations.
2. Protect airway and swallowing. Keep the patient NPO until a formal swallow screen is passed. Speech and bulbar symptoms increase aspiration risk. Monitor oxygen saturation, ECG, glucose, temperature, and neurological status.
3. Urgent imaging
   • Non-contrast CT head to exclude hemorrhage.
   • CTA head and neck, including vertebral and basilar arteries, or MRA, to rule out basilar/vertebral large-vessel occlusion.
   • Review MRI-DWI/ADC and FLAIR carefully, and consider repeat MRI if initial imaging and examination do not match. Very small posterior-fossa strokes can be initially undercalled.
4. Reperfusion treatment if eligible
   • If within the treatment window and no contraindications, IV thrombolysis with tenecteplase or alteplase is considered by the stroke team. Current AHA/ASA guidance supports either agent for eligible acute ischemic stroke within 4.5 hours, and selected imaging-defined patients may be treated later. See the AHA/ASA acute-stroke guideline resource.
   • If CTA shows basilar artery or another treatable large-vessel occlusion, urgent transfer for mechanical thrombectomy is needed. Do not withhold IV thrombolysis just because thrombectomy is being considered, if the patient is eligible.
5. If reperfusion therapy is not used
   • Antiplatelet treatment is usually started after hemorrhage is excluded, but the exact choice and timing depend on whether thrombolysis was given, infarct size, vascular imaging, and bleeding risk.
   • High-intensity statin therapy and risk-factor treatment are standard secondary-prevention measures unless contraindicated.
   • Avoid rapid, unplanned blood-pressure reduction in acute ischemic stroke. BP targets differ before and after thrombolysis/thrombectomy and should be set by the stroke team.
6. Determine cause before discharge
   • Continuous telemetry/ECG, echocardiography when indicated, vascular imaging, lipid profile, HbA1c, blood-pressure review, and assessment for atrial fibrillation, vertebral dissection, atherosclerosis, or embolic source.
   • Anticoagulation is used only when a specific indication exists, such as atrial fibrillation, and is not an automatic acute treatment for every posterior stroke.
7. Early rehabilitation
   • Speech-language assessment, physiotherapy, occupational therapy, mobility assessment, and neuro-ophthalmology/orthoptics review.
   • Temporary patching or prisms can sometimes help disabling diplopia, but only after the ocular-motor pattern is characterized.

Expected outcomes

• Improvement may begin over days to weeks, with further recovery over several months.
• Persistent gaze limitation, diplopia, imbalance, or fatigue can remain, particularly if the lesion involves the pontine gaze center or medial longitudinal fasciculus.
• Prognosis is much worse if there is a basilar artery occlusion, extension of infarction, reduced consciousness, severe dysphagia, or new limb weakness. This is why urgent vessel imaging matters more than the apparent small size of the MRI lesion.

About the medicines given

• LMWH may have been given at a prophylactic dose to prevent leg DVT/pulmonary embolism during reduced mobility. That is common after stroke.
• Or it may have been given at a therapeutic dose for a specific reason, such as proven atrial fibrillation-related embolism, venous thrombosis, or arterial dissection.
• It is not routinely used as the main acute treatment for ischemic stroke, because full-dose anticoagulation does not generally improve acute neurological recovery and can raise bleeding risk. The reason, dose, and planned duration should be clear in the chart.

• Sovateltide is an endothelin-B receptor agonist, marketed in India for acute cerebral ischemic stroke and used as an add-on to standard stroke care, not as a replacement for clot-busting therapy, thrombectomy, antiplatelet therapy, vascular evaluation, rehabilitation, or secondary prevention.
• In the published Indian phase III trial, patients were treated within 24 hours, generally around 18 hours after onset. The study reported better 90-day functional outcomes compared with standard care alone, but it was relatively modest in size, involved 158 patients, and excluded people receiving endovascular therapy. It is promising but should not be viewed as a proven substitute for reperfusion treatment when a treatable large-vessel occlusion exists. See the phase III trial and the ongoing international trial record.
• Do not add, repeat, or stop LMWH, antiplatelets, or sovateltide without the treating neurologist's explicit order.

Ask the treating neurologist today

1. What was the LMWH indication and dose? DVT prevention or full anticoagulation?
2. Has CTA/MRA shown that the basilar and vertebral arteries are patent? If not, why not?
3. Is this a small-vessel infarct, artery-to-artery embolus, dissection, or cardioembolic event?
4. What is the plan for antiplatelet or anticoagulant treatment after LMWH? Aspirin is established acute antiplatelet treatment after ischemic stroke, whereas anticoagulation is tailored to the stroke cause. Harrison’s Principles of Internal Medicine notes aspirin’s established role in acute ischemic stroke (Harrison’s Principles of Internal Medicine, 22e, p. 2548).
5. Has swallowing been screened, and has speech/physio/occupational therapy been started?
6. What are the secondary-prevention measures: statin, BP plan, diabetes control, ECG/telemetry for atrial fibrillation, echocardiogram, and lipid/HbA1c testing?

Immediate escalation while admitted

Immediate measures in hospital

1. Inform the neurology/stroke team immediately if gaze weakness or slurring is new or worsening. Posterior-circulation stroke symptoms can change quickly.
2. Keep the patient NPO: no food, water, tablets by mouth until a nurse or speech/swallow therapist completes a swallow screen. Slurred speech can coexist with impaired swallowing and aspiration risk.
3. Close monitoring
   • Frequent neurological checks: consciousness, speech, pupils, limb power, eye movements, walking/balance.
   • Continuous ECG/telemetry, oxygen saturation, BP, temperature, and blood glucose.
   • Bed rest with fall precautions and assisted mobilization only.
4. Urgent vessel imaging confirmation
   • Ask whether CTA or MRA head and neck has confirmed that the vertebral and basilar arteries are open.
   • This is particularly important with horizontal gaze palsy and dysarthria. If there is a basilar/vertebral occlusion, the stroke team should urgently assess thrombectomy eligibility even if IV clot-busting treatment is no longer possible.
5. Prevent complications
   • Head elevated about 30 degrees if tolerated.
   • Aspiration precautions and oral hygiene.
   • DVT prevention: pneumatic compression and/or the prescribed prophylactic LMWH, depending on bleeding risk and mobility.
   • Treat fever, low oxygen, and low or very high blood glucose promptly.
6. Do not independently add medication
   • Do not add aspirin, clopidogrel, or another blood thinner while LMWH is being given without confirming the neurologist’s plan.
   • Ask exactly whether LMWH is preventive-dose or full treatment-dose, and why it was selected.
7. Start rehabilitation early once stable
   • Speech/swallow assessment.
   • Physiotherapy for balance and walking.
   • Occupational therapy and eye-movement/neuro-ophthalmology assessment if diplopia or persistent gaze palsy occurs.

Call the nurse/doctor urgently for