A 70-year-old, right-handed African American woman with diabetes mellitus, treated with an oral hypoglycemic, and untreated mild hypertension developed right-sided face, arm, and leg weakness while at home preparing breakfast. She was able to reach the telephone and dial 911. An ambulance was summoned, and the Emergency Medical Service team, on arrival, noted a right facial droop, dysarthria, and right-sided weakness. She was transported to a local hospital, arriving within an hour of the onset of the event. The hospital stroke team was consulted and initiated an evaluation.
Physical ExaminationThe patient was afebrile, with a pulse of 72 and a blood pressure of 170/90 mm Hg. Neck was supple with no carotid bruits. Temporal arteries were nontender. Heart was regular with no murmurs or gallops. Peripheral pulses were 2ϩ, and capillary refill was good. There were no peripheral bruits.
Neurological ExaminationShe was awake, lucid, alert, and well oriented. She did not report headache. Speech was dysarthric, but comprehension was good and she spoke in fully formed sentences. There was no sensory neglect or extinction. Cranial nerve examination revealed equal, reactive pupils and full visual fields; funduscopic examination disclosed grade I hypertensive changes. She had a flattened nasolabial fold on the right, but was able to close her eyes and wrinkle her forehead. Motor examination revealed impaired fine motor movements in the right hand, pronator drift of the outstretched right arm, and mild proximal weakness of the right leg; sensory examination revealed decreased vibratory sensation in the distal feet bilaterally. Tendon reflexes were brisk in the right arm; ankle jerks could not be elicited. Plantar response was flexor bilaterally. Coordination in the arms and legs was normal, allowing for proximal weakness. Gait was not tested.
Laboratory StudiesA complete blood count, chemistry profile, coagulation studies, and cardiac enzymes and erythrocyte sedimentation rates were obtained, and were remarkable only for a blood glucose of 175 mg/dL and a sedimentation rate of 20 mm/h. EKG revealed a normal sinus rhythm, with evidence for left ventricular hypertrophy by voltage criteria and nonspecific ST changes. Brain computed tomography (CT) scan revealed age-appropriate atrophy and several small, old, deep white matter infarcts, but no acute changes or bleeds.
Subsequent CourseBased on the acute presentation, the distribution of deficits, and the CT findings, a diagnosis of acute cerebral ischemia was made. There were no contraindications to acute thrombolytic therapy, and with the patient's informed consent after education regarding potential risks and benefits, intravenous tissue plasminogen activator was administered. Subsequent evaluation for the etiology of the stroke included carotid duplex studies and magnetic resonance angiogram of the cervical and intracerebral vessels, which revealed findings consistent with a left internal carotid artery occlusion at the bifurcation. An acute, small deep border zone infarctio...
