Clinical Reasoning: An 81-year-old woman with decreased consciousness and fluctuating right facial droop

Abstract

An 81-year-old woman presented to the hospital after a week of intermittent episodes of decreased level of consciousness, right facial droop, and slurred speech, lasting approximately 30 minutes. Her medical history included chronic obstructive pulmonary disease, dyslipidemia, orthostatic hypotension, and 2 previous TIAs. She had fallen once in the preceding week, presumably as a result of her drowsiness. On examination, she was afebrile with a heart rate of 81 bpm and a blood pressure of 108/65 mm Hg. She was alert and cooperative, but disoriented to the year and location. Language examination was normal. Cranial nerves, motor, coordination, and sensory examinations were all normal without any focal deficits. However, when assessed during one of her episodes, she was less responsive, had decreased verbal output, and was noted to have a right facial droop. Basic serologic tests (complete blood count, electrolytes, renal function tests) were unremarkable. A head CT showed bilateral subarachnoid hemorrhage over the cerebral hemispheres without further abnormality. Questions for consideration: 1. What is your differential diagnosis? 2. Which investigations would you perform at this point? GO TO SECTION 2

Spontaneous ARIA-like Events in Cerebral Amyloid Angiopathy–Related Inflammation

“…There is evidence suggesting CAA-ri as a potentially reversible condition responsive to immunosuppressive therapies, but this is limited to sparse case-reports or small retrospective case series deriving from single centers. 1,[3][4][5][6][7][8][9] Although CAA-ri was thought to be restricted only to CAA patients, the disease is now increasingly recognized and diagnosed in a spectrum of different neurological and neuroradiological manifestations, [10][11][12][13][14][15] including the striking radiographic similarities with the amyloid-related imaging abnormalities (ARIA) observed in some participants within immunization clinical trials for Alzheimer's disease (AD). 1,[16][17][18][19][20][21][22][23] Therapies using anti-Aβ monoclonal antibodies are complicated by 1) ARIA-E (edema), consisting of focal areas of WMH suggestive of parenchymal edema and/or effusion, and 2) ARIA-H (hemorrhage), consisting of CMBs and cSS.…”