title: Clinical Case of the Month: A 49 Year-Old Man Who Presents with Left Sided Weakness: An Update on Ischemic Stroke.
abstract: A 49 year-old man with a past medical history significant for essential hypertension, hyperlipidemia, and coronary artery disease status post percutaneous coronary intervention and stent placement in the right coronary artery in 2010 presented for evaluation of left hemiplegia. He was feeling well until three hours prior to presentation, at which time he fell while walking from his bedroom into the kitchen. After falling, he noticed that his left upper and lower extremities felt weak. He denied any symptoms preceding the fall or any loss of consciousness. On initial exam, the temperature was 99°F, the pulse was 93 beats per minute, the blood pressure was 191/100 mmHg, the respiratory rate was 22 breaths per minute, and the oxygen saturation was 100% while breathing room air. His neurological exam revealed diminished strength in the left upper extremity: 4/5 arm abduction and adduction of the left shoulder; 4/5 elbow and wrist extension and flexion; and 4/5 extension, abduction, and adduction of the digits. The patient also exhibited slight left upper extremity pronator drift. The strength was also diminished in the left lower extremity: 2/5 hip flexion, extension, and rotation; 3/5 knee flexion and extension; and 3/5 ankle dorsiflexion and plantar flexion. Initial NIH stroke scale score was 5, otherwise, there were no focal neurological deficits and the remainder of his exam was unremarkable. Initial computed tomography (CT) of the head was negative for any acute intracranial hemorrhage or infarct. A subsequent CT cerebral perfusion scan (Figure 1) was notable for areas of ischemia in the right cingulate gyrus as well as the medial frontal and parietal lobes. CT angiogram of the neck revealed bilateral atherosclerotic plaque in the carotid arteries; however, there was no evidence of any flow-limiting stenosis.
authors.affiliation: Department of Internal Medicine at LSUHSC-New Orleans; Ochsner Medical Center-Kenner.
authors.forename: Najy
authors.initials: N
authors.lastname: Masri
authors.affiliation: Department of Internal Medicine at Louisiana State University Health Sciences Center in New Orleans, LA.
authors.forename: Rikki
authors.initials: R
authors.lastname: Weems
authors.affiliation: Department of Internal Medicine at the Louisiana State University Health Sciences Center in New Orleans, LA.
authors.forename: Falon
authors.initials: F
authors.lastname: Brown
authors.affiliation: Department of Internal Medicine at Louisiana State University Health Sciences Center in New Orleans, LA.
authors.forename: Ben
authors.initials: B
authors.lastname: Andres
authors.affiliation: Department of Internal Medicine at Louisiana State University Health Sciences Center in New Orleans, LA.
authors.forename: Fred
authors.initials: F
authors.lastname: Lopez
mesh_terms: D000072226:Computed Tomography Angiography / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D018908:Muscle Weakness / Q000209:etiology*; D020521:Stroke / Q000000981:diagnostic imaging* / Q000188:drug therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D010959:Tissue Plasminogen Activator