305 - A case report: Recognizing unilateral rhinorrhea as a rare post-stroke sequelae complication.

A 56-year-old woman with hypertension and substance use disorder presented with one week of left facial droop, weakness, numbness, unsteady gait, and blood pressure of 200/100 mmHg. MRI demonstrated a right middle cerebral artery infarct involving the basal ganglia. After blood pressure was controlled, she was admitted to inpatient rehabilitation. During her course, she developed unilateral left rhinorrhea and eye dryness without diplopia. She received a single dose of cetirizine for symptomatic relief, after which she reported worsening facial droop, blurred vision, and new dysphagia. CT head was negative for recurrent stroke or hemorrhagic conversion. Her symptoms improved by the following day, suggesting cetirizine may have contributed. She was subsequently managed with intranasal fluticasone and erythromycin ophthalmic ointment.

Discussions:

Unilateral intermittent rhinorrhea can occur as a manifestation of sympathetic autonomic dysfunction following stroke. Prior literature suggests that strokes involving both cortical and subcortical regions carry a higher risk of late-onset, often chronic, unilateral rhinorrhea. In our case, the patient developed symptoms approximately one month after her infarct. Additionally, stroke-related facial muscle weakness can impair eyelid closure, predisposing to dry eyes and light sensitivity. For rhinorrhea management, cetirizine was trialed in this case; however, its mild anticholinergic effects may have reduced tear production, thereby worsening her ocular dryness.

Conclusions:

Unilateral rhinorrhea and dry eyes may represent underrecognized post-stroke complications. Caution is warranted when using medications with anticholinergic effects, as they may relieve rhinorrhea but simultaneously exacerbate ocular symptoms, potentially prompting unnecessary emergent workup.