Week 1
11:00-12:00
CEREBROVASCULAR DISEASE
Case 1: A
55-year-old right-handed man with diabetes and
hypertension presented with weakness and numbness of his
right hand, and numbness of the right side of his mouth
that started abruptly 2 hours ago. His wife reported
that he had seen the eye doctor yesterday complaining of
spells of loss of vision in the left eye. Over the last
week, he had three similar spells, each lasting thirty
seconds, which he described as like a shade coming down
over his eye.
Examination disclosed an alert man with blood
pressure of 140/90 and a regular pulse of 78. He had
mild difficultly with both naming and repetition. The
right nasolabial fold was flat relative to the left, but
all other cranial nerve functions were intact.
Subjective numbness was noted over the right distal
hand, with errors exhibited in tests for 2-point
discrimination and graphesthesia. A mild right arm
pronator drift and clumsiness of finger tapping in the
right hand were observed. Reflexes were slightly less
active in the right arm compared to the left, and tone
was mildly diminished on the right. Toes were downgoing.
Head CT was normal.
1. What is the most likely localization of the
neurologic signs and symptoms?
2. In general, what symptoms give firm evidence of
ischemia in the
anterior circulation, what symptoms give
evidence of ischemia in the
posterior circulation, and
what symptoms may be indeterminate?
3. What clinical factors help differentiate
cortical vs. subcortical?
4. What blood vessel is likely involved in this case?
5. What is a
transient ischemic attack (TIA)?; what is
the differential diagnosis of a TIA?
6. How should this patient be investigated and managed?
7. What are the
risk factors for cerebrovascular
disease?
8. Why is the
CT normal despite the obvious clinical
deficit?
Case 2: A
54-year-old hypertensive male suddenly slumped in his
chair while reading. In the ER, he was found to be in a
coma with gasping respirations. Pupils were pinpoint,
but reactive to light. There were no horizontal eye
movements to doll’s head maneuver or calorics. He had a
flaccid quadriplegia. Extensor posturing occurred with
sternal pressure. Bilateral Babinski responses were
present.
1. Describe the probable location of the lesion in
this patient.
2. What is the differential diagnosis in this patient?
3. Describe the
common locations and clinical syndromes
of hypertensive hemorrhages.
Case 3: A
33-year-old right-handed woman developed a sudden and
severe frontal headache, vomited and collapsed. Past
history was unremarkable. Examination revealed a blood
pressure of 180/95, pulse of 56, respirations of 22, and
a temperature of 101.5 deg. F. Neck flexion was
resisted, and Kerning's and Brudzinski's signs were
present. She thrashed about in response to pain, but did
not follow commands. Cranial nerve and funduscopic exams
were negative. No focal weakness was observed. She
withdrew from pin on all four extremities. The left toe
was upgoing to plantar stimulation.
1. What is the likely diagnosis?
2. What entities cause
subarachnoid hemorrhages (SAH)?
3. Where are
saccular (berry) aneurysms most commonly
located?
4. What are common
possible secondary complications of
SAH?
5. What are the
common treatment options of saccular
aneurysms?
Case 4: A 65
year-old African-American man is admitted with new right
sided weakness, present upon awakening in the morning.
There was no prodrome. Prior medical history was notable
for hypertension and diabetes. Blood pressure on
admission was 180/105. Examination showed a moderately
severe right hemiparesis (3/5) affecting the right lower
face, arm and leg. Visual fields were normal. Language
testing was normal. Sensory examination was intact for
touch, pin, vibration and two point discrimination.
Reflexes were depressed on the right with an upgoing
right toe on plantar stimulation.
1. Where is the most likely localization for this
neurologic deficit?
2. What is the most likely etiology?; what is the
underlying pathogenesis?
3. Describe some of the more common
classic lacunar
syndromes.
4. How should the
blood pressure be managed acutely?
5. How should this man be evaluated and treated?
Extra Cases if Time Permits
Case 5: A 21-year-old right-handed man
developed severe left neck pain followed by transient
right hand weakness and difficulty getting his words
out. The neurologic symptoms resolved over 10 minutes
but the neck pain persisted. This occurred shortly after
lifting a large barrel over his left shoulder while
working on a construction site. There was no past
medical history. Neurologic exam was normal other than a
mild left ptosis and a slightly smaller pupil (3 mm) on
the left compared to the right (4 mm). When the lights
were turned off, the pupil asymmetry became much more
marked.
1. What is the significance of the neurologic
findings on examination?
2. Together with the history, what is the most likely
diagnosis?
3. What other
etiologies may cause strokes in the young?
Case 6: A
60-year-old woman presented to the emergency room with
slurring of speech, vertigo, staggering gait, and
difficulty in swallowing. Onset was sudden, with partial
resolution thereafter. Her medical problems included
adult-onset diabetes mellitus, hypertension and mild
angina pectoris. There had been no prior neurological or
cardiac history otherwise of significance. She regularly
took a thiazide diuretic, lisinopril, sublingual
nitroglycerine and an oral hypoglycemic.
Examination revealed an obese woman with a blood
pressure of 190/110, and a pulse of 72 per minute with
occasional irregularities. There were no bruits. Mental
status was normal. Speech was dysarthric. Nystagmus,
beating to the right, was present in primary position.
Slight left sided ptosis and miosis were present. Pin
sensation was impaired on the left side of the face.
Facial strength was intact. The left soft palate did not
elevate voluntarily or during a gag reflex. Facial
sensation was decreased on the left face. Finger-to-nose
intention tremor and impaired rapid alternating
movements were present in the left upper extremity.
Reflexes were symmetric. Muscle tone and strength were
normal in the extremities. Gait was ataxic. Sensory
examination revealed impairment to fine touch and
pinprick on the right side of the body. Vibratory
sensation was normal. CBC, serum electrolytes and
urinalysis were within normal limits. The EKG showed
unifocal PVC's. Head CT was normal.
1. In this patient, where is the lesion most likely,
and how do you explain the exam findings?
2. What blood vessel supplies this area? |
