Agitated confusional states in patients with right hemisphere infarctions

Patients with infarctions in the territory of the right middle cerebral artery (RMCA) sometimes present with an agitated confusional state. We reviewed clinical data on 46 patients with RMCA infarcts and compared neurologic findings in patients with and without agitated confusion. Neither of the two patients presenting with agitated confusion showed obvious localizing neurologic signs; subtle motor, visual field and sensory deficits referable to the infarcted regions were present, but difficult to elicit because of the mental state. In contrast, all but one of the patients without agitated confusion had prominent motor and sensory signs. Infarction of the RMCA territory may cause agitated confusion in patients without prominent localizing signs; the initial neurologic findings may suggest a metabolic encephalopathy. However, the possibility of a cerebrovascular cause should not be dismissed in confused and agitated patients who have no definite lateralizing signs.