Background: Hand knob infarction is a well-known stroke entity. Based on very limited data, embolic stroke mechanism has been considered the most frequent cause; however, prognosis is considered good. We wanted to shed more light on this phenomenon by assessing a cohort of patients referred to a general hospital stroke unit. Methods: Every subject admitted to our stroke unit with an acute isolated hand paresis in the period from 2007 to 2012 was identified prospectively. Patients who had suffered from a stroke in the hand motor cortex or an adjacent area explaining the acute loss of hand function were included in the study. The Trial of Org 10172 in Acute Stroke Treatment criteria were used to classify subtypes of stroke according to etiology. The patients were followed up during autumn 2012. Results: Seventeen subjects were admitted, but in 2 of them symptoms were transitory and magnetic resonance imaging was negative. Two patients were excluded due to persisting sensory deficits. The remaining 13 (11 males and 2 females) patients with an average age of 62.9 (±13.4) years were included, representing 1.5% of all ischemic strokes diagnosed at the stroke unit in the given period. All patients were right-handed, and the dominant hand was affected only in 4 (31%). The average Medical Research Council's scale score was 3.1 (±1.4) on admission, and classified as bad. On follow-up, which occurred on average 29.8 (±19.8) months after the stroke, the score was 4.6 (±0.4) and was classified as fair to good. No patient experienced a new stroke. The outcome was good to excellent in 10 patients (77%). Two patients died (15%), 1 of probable cardiac arrest and 1 of unknown cause. One patient did not participate in the follow-up. The majority of patients had evidence of both small artery (77%) and large artery (85%) disease. On average, there were 1.6 (±0.4) new ischemic lesions per patient. Six patients had a solitary lesion (46%). In 5 of them, small artery occlusion was considered the probable stroke mechanism. In 4 cases, the stroke was of undetermined etiology. Three patients had atrial fibrillation, and in 2 of them cardioembolism was the probable stroke mechanism. Two patients with definite large artery atherosclerosis underwent carotid endarterectomy, and 1 of them had comorbid atrial fibrillation. Conclusion: Strokes causing isolated hand paresis seem to have a heterogeneous etiology. Prognosis regarding hand function is good, but long-term outcome depends on stroke etiology and secondary prophylaxis.
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A 48-year-old man with no previous medical history suddenly experienced severe intense retro-bulbar pain of pulsating character on the right side, and was seen in the emergency department 7 hours later. He was then alert and oriented, but in excruciating pain. There was no neck stiffness and no fever. The blood pressure was 141/80 mm Hg, and the pulse regular with a frequency of 48. Neurological examination was normal. Query by Dr. Sjulstad: When does actually sudden-onset severe headache represent a potential life-threatening condition?Response by Dr. Alstadhaug: There is no definite answer to that question. Atypical presentation of subarachnoid hemorrhage (SAH) with mild, or slowly progressive headache over minutes, and even absence of headache may occur in up to 3.8% of patients as reported in a recent Japanese study, 1 but previously up to 10% has been reported. 2 In a case series with 42 patients who had bled from an aneurysm, the headache came instantly in 50%, after 2-60 seconds in 24%, and within 1-5 minutes in 19%. 3 In 10%-40% of patients with diagnosed bleeding from an aneurysm, there has been an episode with hyperacute headache prior to the one that led to the diagnosis. 4 Such a warning leak has typically been reported to occur a couple of weeks earlier, but the risk of re-bleeding after SAH is highest within the first 24 hours. Non-ruptured aneurysms may also cause headache (dissection in the aneurysm wall, acute expansion or thrombosis), but more often they cause focal symptoms/signs due to mass effect Headache
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