Neurology · Year 3 · from Neurology

Case 1: Right MCA Stroke with Classic Localization

Patient Demographics

  • Age: 68 years
  • Sex: Male
  • Occupation: Retired accountant

Chief Complaint

"My left arm and leg stopped working, and I can't speak properly."

History of Present Illness

The patient was eating breakfast when his wife noticed his face drooping on the left side. He dropped his coffee cup and was unable to lift his left arm. His speech became slurred and he had difficulty finding words. Symptoms onset was 2 hours ago. Past medical history includes hypertension, hyperlipidemia, and atrial fibrillation (not on anticoagulation).

Neurological Examination Findings

Mental Status:

  • Alert but frustrated
  • Expressive aphasia - speaks in telegraphic phrases, good comprehension
  • Oriented to person and place, difficulty with date

Cranial Nerves:

  • Left lower facial droop (CN VII - UMN pattern: forehead spared)
  • Left-sided neglect on visual fields
  • Eyes deviated to the right
  • Pupils equal and reactive

Motor Examination:

  • Left upper extremity: 0/5 strength (flaccid initially)
  • Left lower extremity: 2/5 strength
  • Right side: 5/5 strength throughout
  • Left pronator drift present

Sensory Examination:

  • Decreased sensation to light touch and pinprick on left face, arm, and leg
  • Extinction to double simultaneous stimulation on left

Reflexes:

  • Left upper and lower extremity: 3+ (hyperreflexia developing)
  • Left Babinski sign positive (upgoing toe)
  • Right side: 2+ throughout

Coordination:

  • Unable to assess left side due to weakness
  • Right finger-to-nose and heel-to-shin normal

Gait:

  • Unable to ambulate

Localization

Lesion Location: Right middle cerebral artery (MCA) territory

  • Left hemiparesis (contralateral motor cortex/internal capsule)
  • Left facial droop with forehead sparing (UMN pattern - CN VII)
  • Expressive aphasia suggests left hemisphere, but patient is left-handed
  • Right gaze preference (frontal eye fields)
  • Left-sided neglect (right parietal lobe)
  • UMN signs (hyperreflexia, Babinski) = cortical/subcortical lesion

Neuro Workup

  • NIHSS Score: 14
  • CT Head without contrast: Hyperdense right MCA sign, early loss of gray-white differentiation in right insula
  • CT Angiography: Occlusion of right M1 segment of MCA
  • CT Perfusion: Large ischemic penumbra with small core infarct
  • Labs: INR 1.0, glucose 142, platelets 198K

Diagnosis

Acute right MCA ischemic stroke secondary to cardioembolic source (atrial fibrillation)

Management

  1. IV alteplase (tPA) administered within 3-hour window
  2. Mechanical thrombectomy performed - successful recanalization (TICI 2b)
  3. Admit to Neuro ICU for blood pressure management
  4. NPO until swallow evaluation
  5. Initiate anticoagulation after 24-48 hours for secondary prevention
  6. Physical therapy, occupational therapy, speech therapy consults
  7. Risk factor modification: continue antihypertensives, statin

Clinical Image

Image Description: CT angiography showing occlusion of the right middle cerebral artery (M1 segment) with absence of distal flow.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/mca-occlusion-ct-angiography

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