Neuroscience · Year 2 · from Neuroscience
Case 1: Middle Cerebral Artery Stroke - Dominant Hemisphere
Patient Presentation
Demographics: 72-year-old right-handed female
Chief Complaint: Sudden onset right-sided weakness and difficulty speaking, last known well 90 minutes ago
History of Present Illness: The patient was eating breakfast with her husband when she suddenly dropped her coffee cup. Her husband noticed her right arm was limp and she could not speak coherently. She attempted to stand but fell due to right leg weakness. Emergency medical services were called immediately. Her medical history includes hypertension, atrial fibrillation (on warfarin), and hyperlipidemia. Her husband reports she ran out of warfarin two weeks ago and has not refilled it.
Physical Examination:
- Vital signs: BP 178/96, HR 88 irregularly irregular, T 37.0C
- General: Awake, frustrated appearing, attempting to speak but producing only garbled sounds
- Neurological:
- Mental status: Alert; follows simple one-step commands inconsistently; severe expressive aphasia with only stereotyped sounds "ba ba ba"; comprehension appears moderately impaired
- Cranial nerves: Eyes deviated to the left; right homonymous hemianopia on visual threat; right facial droop (lower face)
- Motor: Right arm 0/5 (plegic), right leg 2/5, left side 5/5
- Sensory: Does not respond to pinprick on right side; responds on left
- NIHSS Score: 18
Workup:
- Non-contrast CT head: No hemorrhage; subtle loss of gray-white differentiation in the left insula and lentiform nucleus (early ischemic changes)
- CT angiography: Complete occlusion of left M1 segment of MCA; ICA patent
- CT perfusion: Large perfusion deficit with small core (<15 mL) and large penumbra (>100 mL); favorable core-penumbra mismatch
- INR: 1.3 (subtherapeutic)
- ECG: Atrial fibrillation with rapid ventricular response
Diagnosis: Acute left MCA territory ischemic stroke due to cardioembolic occlusion of M1 segment
Treatment:
- IV alteplase 0.9 mg/kg (given within 2.5 hours of last known well)
- Emergent mechanical thrombectomy performed with successful recanalization (TICI 3)
- Blood pressure management
- Aspirin held for 24 hours post-thrombolysis, then initiated
- Anticoagulation with apixaban initiated after 7 days (given stroke size)
Clinical Course: The patient showed dramatic improvement following thrombectomy. By 24 hours, she had 4/5 strength in the right arm and 5/5 in the right leg. Her speech improved to fluent but with word-finding difficulties (anomic aphasia). At discharge on day 7, NIHSS was 4. At 3-month follow-up, she had mild residual right arm weakness and occasional word-finding pauses but was independent in all activities.
Clinical Pearl: MCA strokes in the dominant hemisphere produce the classic triad of contralateral hemiparesis (face and arm > leg), hemisensory loss, and aphasia. The eye deviation toward the lesion ("eyes look at the lesion" in cortical strokes) occurs because the frontal eye fields that drive conjugate gaze to the opposite side are damaged. Thrombectomy has revolutionized treatment for large vessel occlusions, with number needed to treat as low as 2-4 for good outcomes.