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Case 392

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A 84-year-old man with a history of smoking (75 pack-years) and alcoholism, no other comorbidity related, presented with dysarthria, right hemiataxia and hemiparesis, mainly in the right arm, after fall on waking. Physical examination showed verbal response, isochoric and photoreactive pupils, Babinski positive on the right, sinus rhythm on ECG. Brain magnetic resonance and magnetic resonance angiography were requested.

According to the clinical history and the radiological exams presented, what is the probable etiology for the neurological condition?

a) Cardioembolic stroke caused by atrial fibrillation, which occludes the flow of the right posterior cerebral artery.

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b) Artery-to-artery embolic stroke, which occludes the flow of the left posterior cerebral artery.

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c) Lacunar infarction, occlusion of a thalamic small penetrating artery, branch of the left posterior cerebral artery.

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d) Artery-to-artery embolic stroke originated from left carotid atherosclerosis, occluding the left posterior cerebral artery.

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Image analysis

Image 1: Magnetic resonance (MR) image of the brain, axial section, T2-weighted fluid-attenuated inversion recovery image, showing hypersignal in a small left thalamic area (red arrow).

Image 2: Magnetic resonance (MR) image of the brain, axial section, diffusion-weighted image (DWI), showing hypersignal in a small left thalamic area (red arrow).

Image 3: Magnetic resonance angiography of the neck, showing left common carotid artery (A.C.C.E) and left Internal Carotid Artery (A.C.I.E), no flow occlusion evidenced. No flow occlusion was evidenced in the right carotid circulation and it was purposely hidden in this reconstruction.

Image 4: Cerebral Magnetic resonance angiography, showing left posterior cerebral artery occlusion (dotted red circle) and suspected atheromatous plaque in the right vertebral artery, intradural segment (yellow arrow).

Highlights

-       Stroke is the second leading cause of death and disability worldwide, affecting an average of 15 million people every year.

-       Hypertension is the mainly risk factor, followed by hyperlipidemia, atrial fibrillation, smoking, diabetes and advanced age.

-       The ischemic stroke is responsible for 80% of all stroke cases, cardioembolic and artery-to-artery stroke are its mainly etiology.

-       Ischemic and hemorrhagic stroke must be distinguished to guide the right treatment. CT is the most used method to exclude cerebral hemorrhage in the acute phase of stroke.

-       Intravenous thrombolysis must be initiated beyond the 4.5-h window. The time of stroke onset is defined as the time the patient’s symptoms were witnessed to begin or the time the patient was last seen as normal.

References

- Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J et al. Harrison's principles of internal medicine. New York: McGraw Hill Education; 2015.

- Regenhardt R, Das A, Lo E, Caplan L. Advances in Understanding the Pathophysiology of Lacunar Stroke. JAMA Neurology. 2018;75(10):1273.

- Thaissa F, Vanessa S, Fernanda F. Acidente Vascular Encefálico Isquêmico: do diagnóstico à terapêutica. Revista Medica de Minas Gerais. 2010; 20.2(Supl 1):98-100.

- Boehme A, Esenwa C, Elkind M. Stroke Risk Factors, Genetics, and Prevention. Circulation Research. 2017;120(3):472-495.

- Furie K. Epidemiology and Primary Prevention of Stroke. CONTINUUM: Lifelong Learning in Neurology. 2020;26(2):260-267.

- Goldman L, Ausiello D. Cecil medicina. 23rd ed. Rio de Janeiro: Elsevier; 2009.

Author

Ana Clara de Paula Caldas, 3rd year medical student.

E-mail: anacpcaldas [at] gmail.com

Supervisors

Dr. Paulo Pereira Christo, neurologist at the Hospital das Clínicas da UFMG

E-mail: ppchristo [at] gmail.com

 

Dr. Rafael Lourenço, neuroradiologist.

E-mail: rafael.lourenço [at] gmail.com

Reviewers

Leandra Diniz, Lara Hemerly de Mori, Larissa Rezende, Victória Costa, Mariana Mestriner, Prof. Júlio Guerra Domingues.

Translated by

Ana Clara de Paula Caldas, 3rd year medical student.

E-mail: anacpcaldas [at] gmail.com

Test question

(UNIFESP 2015 - Intensive Care Medicine) A 49-years-old patient presented to the emergency room with his brother, who reported that he had a sudden loss of strength in the left arm, he also presented a difficulty of communication. Both symptoms started 35 minutes ago during physical activity at the gym. Past medical history: systemic arterial hypertension and smoking. On examination: alert, obeying commands, total right hemiparesis with brachio-facial predominance (muscle strength grade II). Afasia, no stiff neck, isochoric and photoreactive pupils. Blood pressure: 190/110 mmHg. Heart rate: 88bpm; RF: 14. Computed tomography of the brain and laboratory tests were normal. What is the probable diagnosis and the more appropriate management?

a) Subarachnoid hemorrhage. The evolution should be carefully observed, with magnetic resonance imaging performed as soon as possible.

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b) Transient ischemic stroke. In view of the time lapse, it is not a candidate for reperfusion thrombolytic therapy. It is not recommended to control the hypertension in this acute phase.

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c) Ischemic stroke. In view of the time lapse, he is not a candidate for reperfusion thrombolytic therapy. Aspirin and neurological surveillance are recommended.

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d) Ischemic stroke. In view of the time lapse, this is a candidate for reperfusion thrombolytic therapy with r-tPA. However, it is necessary an adequate pressure control and to make sure of the absence of other contraindications.

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e) Hemorrhagic stroke. It is recommended an adequate pressure control and repeat the tomography in the first 24 hours.

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