Sudden-onset restless legs syndrome due to acute cerebral hemorrhage

Restless legs syndrome (RLS) is generally considered a chronic neurological condition or a post-stroke complication. However, its sudden onset as a presenting feature of acute stroke is rarely reported. We present a case of acute cerebral hemorrhage manifesting solely as sudden-onset RLS without other neurological deficits. A 58-year-old woman experienced an abrupt onset of an irresistible urge to move her legs. Upon arrival at the emergency department, she continued to experience this urge and displayed rhythmic leg trembling. Moving her legs relieved her discomfort, and she was able to consciously suppress the movements. Neurological examination revealed no motor or sensory deficits. Subsequent head computed tomography revealed a hemorrhage involving the lentiform nucleus and the body of the caudate nucleus, with sparing of the pyramidal tract. On hospital day 3, oral pramipexole was initiated, resulting in a gradual improvement of her RLS symptoms. She was discharged without neurological abnormalities. Restless leg syndrome may be an initial manifestation of acute stroke. Emergency physicians should consider the possibility of acute stroke in the differential diagnosis of sudden-onset involuntary movements resembling RLS, even in the absence of focal neurological deficits.