Case Report: Asymmetric recovery unmasking watershed infarction in a patient with ICU-acquired weakness

A case report describes a 59-year-old female with severe pneumonia and septic shock who developed profound muscle weakness after surviving acute respiratory failure. Initially, the generalized weakness was attributed to ICU-acquired weakness, supported by electrophysiological studies and muscle biopsy findings. However, the patient exhibited asymmetric motor recovery with persistent left-sided deficits despite a negative brain CT scan. Subsequent MRI revealed fresh watershed infarctions in the right hemisphere. A tailored rehabilitation strategy focusing on mitochondrial metabolism and active physical therapy led to significant functional improvement, with complete recovery reported at two-year follow-up. The case highlights that the weaning process can act as a hemodynamic stress test, unmasking latent cerebrovascular fragility in complex ICU patients.