Case Studies

Case 1

 72 yrs, F,

 Sudden onset of right arm and leg weakness for 3 hrs, admitted to emergency room

 No loss of consciousness, vertigo, vomiting , seizure

 PE:

 Right mouth corner lower

 Tongue deviate to the right while show it

 Muscle power: 3/5 right arm; 2/5 on the right leg

 Reduced pain sensation on the right trunk and limbs

 Babinski’s sign(+) on the right side

Q1: where is the lesion? Why?

Q2: what is the probable cause? Why?

Answer:

Evidence1:

 the lady has only right limbs weakness and numbness, babinski(+),

 No vertigo and vomiting means there were novetebral-baslar system affected
 the most probable location was left MCA.

Evidence 2

 both of the motor and sensation of right limbs were affected,

 but there were no disturbance of consciousness, which means the lesion was not very big
 (if very big, there would be disturbance of consciousness) and the nerve fibers must highly
constructed.
 the only one place was baslar ganglia(left).

the most commom cause of elderly patients stroke was atherosclerosis.

Embolic infarction

• An infarct caused by an embolus.

• Sources of thrombi
 – Carotid bifurcation (embolic-artery to artery)

– Heart (cardioembolic- atrial fibrillation, patent foramen ovale, infective endocarditis, left
ventricular failure)

– Undetermined origin

Clinic feature

• Suddenly, within seconds

• Most during activity

• Symptoms disappear faster

• Because the embolic blockage is sudden in onset, symptoms usually are maximal at start. Also,
symptoms may be transient as the embolus is partially resorbed and moves to a different
location or dissipates altogether

★ Thrombotic infarction Embolic infarction

Age Older(>60) young adult

Causes Atherosclerosis Cardiac diseases

TIA common rare

Activity At rest During activity

Onset Slow (hours,days) Fast (seconds)

Consciousness Disorders (-)/mild Rare/short

Blood pressure Normal/mild high normal

Fundus Oculi arteriosclerosis normal

Lacunar infarction

• Lacunes are small (<1.5 cm3) infarcts seen on MRI or at autopsy.

★Hypertension is commonly present

◦ pure motor stroke

◦ pure sensory stroke

◦ unilateral ataxia

◦ dysarthria with a clumsy hand

• often symptomless

Watershed infarction

• Infarction in the border between two main arteries

• Elderly, >50 years old

• Most with hypotension

• A watershed stroke refers to the condition when blood supply to these areas is compromised.

Case 2

 42 yrs, Female

 Blurred vision on the right eye for 1 month, recovered well

 Numbness below the waist for 1 wk, spontaneously recovered

 Blurred vision on the left eye for 3 days, admitted

 PE:Pale optic disc on the right, normal left, Reduced pin sensation on R. leg, Babinski’s sign(+)

Q1: where is the lesion? Why?

Q2: what is the probable cause? Why?

Case 3
 male，31yrs

 Difficulty swallowing and hoarseness for 3 days

 Accompanied by weakness on all limbs 1day

 Accompanied by breathing difficulty for 4 hours

 PE

 Incubated, without loss of consciousness

 Bilateral abduction impaired

 Weakness on eye closing, showing teeth

 Absent gag reflex

 Muscle power: 3/5, with decreased muscle tone

 Absent tendon reflex on all limbs, without Babinski’s sign

 Decreased pin sensation on distal end of arms and legs

Q1: where is the lesion? Why?

Q2: what is the probable cause? Why?

ANS1:Lower motor neuron lesion

ANS2:Inflammation,infection

Case 4

 72 year old man ,wakes up one morning and has

difficulty reading the newspaper

Q1: where is the lesion? Why?

Ans: Occipital lobe: infarction/tumor/trauma

Q2: what is the probable cause? Why?

Ans: inflammation (optic neuritis) /Tumor(glioma) / Ischemic

Case 5
 53 year old woman reports diplopia and right upper lid ptosis for about one month. She has no
other symptoms. She has poorly controlled diabetes

 What are the abnormalities shown on this video?

 Where is the lesion?

 What studies would you order?

Case 6

A 75 years old presents to the emergency room with a 2-day history of low grade fever and 1 day of
increasingconfusion and headache. He has type 2 diabetes that is poorly controlled with oral
medication, chronic osteoarthritis, and a previous heart attack 3 years ago. On examination, his
temperature is 37.7Ç. He has no focal neurologic findings but his neck is stiff in all directions. His wife
says that his neck is always stiff.

 Should meningitis, particularly bacterial meningitis, be suspected?

Answer: Person is old low fever, increasing confusion, headache..

Meningeal irritation sign is positive: neck stiffness
All these sign show meningitis particularly bacterial meningitis
Which can be further confirmed by CSF Analysis and Gram staining…..

Case 7

A 40 year old divorced woman presents with a one day history of a new splitting headache and nausea.
She is otherwise healthy and denies a history of migraine headaches or genital herpes simplex. She has a
normal general exam without evidence of vesicles in the genital area and has only a mild stiff neck. Her
mental status is normal. Her fever is 36.8Ç.

 Should bacterial or viral meningitis be considered?

 A lumbar puncture has an opening pressure of 185 mm CSF, 100 WBC/mm3 with a predominance
of lymphocytes, glucose of 52mg/dl with accompanying blood glucose of 88 mg/dL, and protein of
95 mg/dL. Gram stain of CSF sediment is negative for bacteria. The CSF PCR assay for Herpes
simplex virus, type 2 returned positive.

Answer 1: viral meningitis

Answer 2:HSV 2 POSITIVE

Case 8

A 50 year old previously healthy woman on Valentine's day presents with the acute onset of confusion
and delirium and a low grade fever. She lacks a headache or meningismus. Her general physical exam is
unremarkable. A lumbar puncture shows an opening pressure of 180 mm CSF, lymphocytic pleocytosisof
45 cells/mm3, glucose of 48 mg/dL, protein of 75 mg/dL, and negative Gram stain of CSF sediment. Her
MRI shows a hyperintense lesion only in the left temporal lobe. Later that day her CSF PCR assay for
herpes simplex virus returns negative.

 How worried are you that she may actually have herpes simplex encephalitis?
 What evidence is there to support a diagnosis of HSE and start acyclovir?
 How can you confirm the diagnosis?

Answer 1:

 Low grade fever

 Onset of confusin and delirum
 Negative gram stain of csf
 Lesion in the left temporal lobe

Answer 2: Her MRI shows a hyperintense lesion only in the left temporal lobe

Answer 3: CSF, EEG, MRI ,PCR ASSAY

Case 9:

 A 3-year-old boy is brought to his pediatrician to be evaluated for difficulty walking and clumsiness.
 According to his parents, the patient began walking at the age of 18 months, but in the past year he
has begun to fall more frequently and has difficulty getting up from the floor; often supporting
himself with his hands along the length of his legs. Birth and developmental history until symptom
onset are reportedly normal. There is no contributing family history.
 On physical examination the young boy has significant muscle weakness of his hip flexors, knee
extensors, deltoids, and biceps muscles. His calves are large, and he walks on his toes during
ambulation.
 Laboratory studies reveal an elevated serum creatine kinase (CK) level of greater than 900.
 Electromyography of his muscles reveals a myopathy. Nerve conduction studies reveal relative
normal nerve function.
 What is the most likely diagnosis?
 What is the next diagnostic step?
 What is the next step in therapy?

Answer 1: Pseudohypertrophic muscular dystrophy

Particulary Duchenne muscular dystrophy

Answer 2:

 EMG
 MUSCLE BIOPSY
  GENE

Answer 3: Treatment: limited, just for the symptoms

Case 10:

 History: 57 year old female,Sudden onset, severe headache,Took ASA for

relief,Slurredspeech,Collapsed
 PE: T 99.4 P52 BP 195/99 RR13, Pupils-2 mm reactive, Neck-no JVD, bruits, CV-bradycardia, no
murmur, Abd-bs+, soft , nt/nd,Skin-warm and dry
 Neurological exam:no gag reflex, withdraws to pain, +4 DTR
 GCS: Eyes-1, Verbal-1, Motor-4
 NIHSS Score: Stroke scale 25
1. What's the optimal ED management of a patient with ICH?
2. What are the goals of BP management?
3. Why is ICP important?
4. What are the optimal strategies for managing ICP?
5. What other treatment modalities are available to the ED physician?
6. Which ICH patient require surgery?
7. How does hemorrhage volume affect mortality?
8. What are the new therapies being tested for this disease process?
Answer 1:
 1:Resuscitation of the patient-regardless of ICP
 2:Assume elevated ICP in head injury/altered MS patient
 3:ABCs-as all good ED physician would do

Answer 2:

 Monitor BP
 Cautiously lower blood pressure to a mean arterial pressure (MAP) less than 130 mmHg, but
avoid excessive hypotension

Answer 3:

 Intracranial Pressure (ICP): considered a major contributor to mortality when elevated

 Correlation between elevated ICP and poor outcome
 Increased risk of
 Herniation
 Decreased Cerebral perfusion

Answer 4:

 Controlling ICP is considered essential

 Osmotherapy
  Hyperventilation
 Barbiturate coma

Answer 5:

 BP management
 Hyperventilation
 Endotracheal intubation
 Fever management
 seizure therapy
 medical therapy
 steroids

Answer 6:

 Cerebellar hemorrhage > 3 cm who are deteriorating or with brain stem compression and
hydrocephalus from ventricular obstruction
 Vascular malformation if lesion is surgically accessible and patient has chance for good outcome
 Young patients with a moderate or large lobar hemorrhage who are clinically deteriorating

Answer 7:
Worse

 Volume > 60 cm3 and GCS < 9

 91% dead at 30 days
 Patients with volume over 30 cm3 only 1 / 71 independent at 30 days
 Intraventricular extension

Better

 Volume < 30 cm3 and GCS 9 or higher

 19% dead at 30 days

Ans 8: There are promising new therapies such as Factor VII on the horizon

CASE 11:
A 67-year-old man came to the hospital because of recurrent transient loss of vision in the left eye and
sensorimotor hemiparesis of the right side. He had repeatedly had these symptoms during the previous
5 days, occurring for approximately 3–5 minutes and completely resolving.

The transient visual loss appeared as a shade that descended over the left eye, usually clearing within 1
minute. The visual loss and right sided weakness occurred in different attacks, not together

General history

Hypertension, cigarette smoking (20-pack–years), hyperlipidemia; no previous neurological symptoms.

Examination: no abnormalities

A high grade stenosis with a local stenosis grade of 80% of the left extracranial ICA was present on
ultrasound with a maximum systolic peak velocity of 2.8m/s.

Questions:

Q1: The localization diagnosis of this patient is most probably located in: (write down the location of the
brain and the artery mostly influenced)

Q2: The main diagnosis of this patient.

Q3: The main treatment of the patient.

Answer

Localization diagnosis:

transient loss of vision in left eye

sensorimotor hemiparesis of the right side

Stenosis in left extracranial ICA

(left hemisphere and left eye\Ophthalmic Artery and left MCA)

Main diagnosis: Old man, Risk factors(hypertention\ cigarette smoking \ hyperlipidemia) Recurrent and
repeated

Examination: no abnormalities

Dx :Transient Ischemic Attack (TIA)

Treatment:

1:Anti-platlet agents
Aspirin(100-325mg,daily)

Clopidogrel(75mg,daily)

2:Anticoagulants( not a routine for TIA)

fibrillation atrial

prosthetic valve replacement

INR 2.0-3.0

3:Surgical management

Angioplasty and stenting (70%-90%)

Surgical treatment :Endarterectomy (>90%)

CASE 12

• A 52-year-old woman was admitted to the stroke unit 5 hours after onset of a slight sensory–
motor hemiparesis of the left extremities and a slight dysarthria accompanied by a dull right
occipital headache.

• The patient weighed 119 kg with a BMI 43.

• Type II diabetes for 10 years,

• with symptoms of diabetic retinopathy and neuropathy;

• hypertension and hypercholesterolemia.

• CT showed a territorial infarction in the right MCA territory from the insular/perisylvian to the
parietal cortex, involving mainly the superior division of the MCA but sparing the lenticulostriate
territory.

• Follow-up MRI performed 1 year after the patient’s stroke demonstrates a cystic lesion with
atrophy and perilesional T2-hyperintensity in the right MCA territory on FLAIR images.