Motor posturing in acutely comatose patient is suggestive of an evolving brain herniation. In the presence of a unilateral pupillary abnormality, a metabolic or drug induced coma can be excluded. Neuroimaging studies in such cases will likely reveal underlying mass or acute ventricular obstruction. We recently encountered a patient who presented in stupor with repetitive motor posturing and a transient right oval pupil to light stimulus. Surprisingly, an urgent brain CT revealed only mild global atrophy for age. Further evaluation disclosed cryptococcus meningitis as the underlying cause.

This is the report of an anterior communicating artery aneurysmal coil as the likely source of septic emboli resulting in bilateral hemispheric abscesses sparing the medial frontal, parietal and occipital lobes and brainstem. Cessation of antegrade anterior cerebral artery flow and resulting turbulent flow into the distal cortical arterial watershed of middle cerebral artery territory bilaterally is the probable mechanism for this unusual pattern.