# Clinical Cases: Stroke and Cerebrovascular Disease ## Case 1: Acute Ischemic Stroke - Thrombolysis and Thrombectomy ### Patient Presentation **Demographics:** 64-year-old male **Chief Complaint:** Sudden right arm and leg weakness with slurred speech; last known well 75 minutes ago **History of Present Illness:** The patient was watching television with his wife when she noticed his speech suddenly became slurred and his right arm dropped. She called 911 immediately. EMS noted right hemiparesis and activated the stroke code en route. The patient has a history of hypertension (on lisinopril), type 2 diabetes, hyperlipidemia, and former smoking (quit 5 years ago). **Pre-Hospital:** - EMS Cincinnati Stroke Scale: Positive (facial droop, arm drift, speech abnormality) - Glucose: 156 mg/dL - Blood pressure: 182/98 **Emergency Department Evaluation:** - Time from last known well: 75 minutes - Vital signs: BP 178/96, HR 88, T 36.9C **NIH Stroke Scale Assessment:** - Level of consciousness: 0 - LOC questions (month, age): 0 - LOC commands (close eyes, make fist): 0 - Best gaze: 1 (partial gaze palsy - eyes deviate left) - Visual fields: 2 (complete hemianopia - right visual field cut) - Facial palsy: 2 (partial paralysis - right lower face) - Motor arm (left): 0 - Motor arm (right): 3 (no effort against gravity) - Motor leg (left): 0 - Motor leg (right): 2 (some effort against gravity) - Limb ataxia: 0 (cannot assess weak limbs) - Sensory: 1 (mild-moderate loss on right) - Best language: 1 (mild-moderate aphasia) - Dysarthria: 2 (severe) - Extinction: 1 (visual extinction) - **Total NIHSS: 15** **Imaging:** - CT head without contrast: No hemorrhage; hyperdense MCA sign on left (clot in artery); early loss of insular ribbon on left - CT angiography: Complete occlusion of left M1 segment of MCA - CT perfusion: Core infarct volume 12 mL; penumbra 110 mL; large mismatch favorable for intervention **Laboratory:** - Glucose: 164 mg/dL - INR: 1.0 - Creatinine: 1.1 mg/dL - Platelet count: 245,000 **Diagnosis:** Acute left MCA territory ischemic stroke due to large vessel occlusion (M1 occlusion) **Treatment:** *IV Thrombolysis:* - Blood pressure lowered to 178/94 (below 185/110) - Alteplase 0.9 mg/kg (79.2 mg total for 88 kg patient) - 10% (7.9 mg) IV bolus - Remainder (71.3 mg) infused over 60 minutes - Door-to-needle time: 42 minutes *Mechanical Thrombectomy:* - Patient transferred immediately to angiography suite - Right femoral artery access - Catheter advanced to left MCA - Stent retriever deployed and clot retrieved - TICI 2c reperfusion achieved (near-complete) - Door-to-groin puncture: 78 minutes *Post-Intervention:* - Blood pressure maintained <180/105 for 24 hours - CT at 24 hours: Small infarct in left basal ganglia; no hemorrhagic transformation - Aspirin 81 mg started at 24 hours - DVT prophylaxis - Swallowing evaluation **Clinical Course:** - 2 hours post-thrombectomy: NIHSS improved to 8; patient lifting right arm against gravity - 24 hours: NIHSS 5; mild residual weakness and word-finding difficulties - Discharge day 5: NIHSS 3; walking with assistance; mild dysarthria - 90-day follow-up: Modified Rankin Scale 1 (no significant disability); returned to work **Clinical Pearl:** The combination of IV thrombolysis and mechanical thrombectomy for large vessel occlusion represents the modern standard of care. The "time is brain" principle is demonstrated by the favorable outcome with rapid treatment (door-to-needle 42 minutes, door-to-puncture 78 minutes). The penumbra (salvageable tissue) is the therapeutic target; CT perfusion identifies patients likely to benefit even in cases outside traditional time windows. The number needed to treat for thrombectomy is remarkably low (2-4). --- ## Case 2: Lacunar Stroke - Pure Motor Hemiparesis ### Patient Presentation **Demographics:** 71-year-old female **Chief Complaint:** Right arm and leg weakness noticed upon awakening **History of Present Illness:** The patient went to bed feeling well but woke this morning with weakness affecting her right arm and leg equally. She has no facial weakness, no speech difficulty, and no numbness. She has a long history of hypertension (often not taking medications consistently) and type 2 diabetes. **Physical Examination:** - Vital signs: BP 168/94, HR 72, T 36.8C - General: Comfortable, conversant **Neurological Examination:** - Mental status: Alert, oriented, cognition intact - Language: Fluent, intact naming, comprehension, and repetition - NO APHASIA - Cranial nerves: - Visual fields: Full - NO HEMIANOPIA - Face: Mild right lower facial weakness - All others intact - Motor: - Right upper extremity: 3/5 throughout (deltoid, biceps, triceps, grip) - Right lower extremity: 3/5 throughout (hip flexors, knee extension, ankle) - Left side: 5/5 - Sensory: INTACT to light touch, pinprick, and proprioception bilaterally - NO SENSORY DEFICIT - Reflexes: Right side 3+, left side 2+; right Babinski present - Coordination: Unable to assess right side due to weakness; left normal - Gait: Unable to walk without assistance **Key Observation:** Pure motor deficit without cortical signs (no aphasia, no neglect, no hemianopia, no sensory loss) **Imaging:** - CT head: No hemorrhage; no early ischemic changes - MRI brain with DWI: Small (12 mm) focus of restricted diffusion in the left posterior limb of the internal capsule **Workup:** - HbA1c: 8.9% - LDL: 145 mg/dL - ECG: Normal sinus rhythm - Echocardiogram: Normal; no cardioembolic source **Diagnosis:** Lacunar infarct of left posterior limb of internal capsule - Pure motor hemiparesis syndrome **Treatment:** - Aspirin 81 mg daily - High-intensity statin (atorvastatin 80 mg) - Blood pressure optimization (goal <130/80) - Diabetes management with endocrinology referral - Physical therapy for gait training and strengthening - No thrombolysis/thrombectomy (small vessel disease, not large vessel occlusion) **Clinical Course:** The patient's strength gradually improved over 4-6 weeks. At 3-month follow-up, she had 4+/5 strength in right extremities and was walking independently. Blood pressure was controlled at 128/78, and HbA1c had improved to 7.4%. **Clinical Pearl:** Lacunar infarcts result from small vessel disease (lipohyalinosis) affecting penetrating arteries, typically in the setting of chronic hypertension. They produce characteristic clinical syndromes: pure motor hemiparesis (most common - posterior limb of internal capsule or pons), pure sensory stroke (thalamus), ataxic hemiparesis, and dysarthria-clumsy hand. The absence of cortical signs (aphasia, neglect, visual field cut) is the key diagnostic feature. Treatment focuses on aggressive vascular risk factor management rather than thrombolysis/thrombectomy, as the occlusion involves small perforating vessels. --- ## Case 3: Intracerebral Hemorrhage on Anticoagulation ### Patient Presentation **Demographics:** 76-year-old male **Chief Complaint:** Sudden severe headache and left-sided weakness **History of Present Illness:** The patient was reading when he suddenly developed a severe headache and noticed his left arm felt weak. His wife noted he seemed confused and had difficulty speaking. He has atrial fibrillation and has been taking warfarin for 5 years. He also has a history of hypertension and chronic kidney disease. **Physical Examination:** - Vital signs: BP 198/108, HR 88 irregular, T 37.2C - General: Drowsy, oriented to person only - Neurological: - Mental status: Lethargic; follows simple commands inconsistently - Cranial nerves: Eyes deviated to the right; left homonymous hemianopia; left facial droop - Motor: Left arm 1/5, left leg 2/5, right side 5/5 - Sensory: Does not respond to pinprick on left - NIHSS: 18 **Imaging:** - CT head without contrast: 45 mL hyperdense (bright white) hemorrhage in right basal ganglia with mass effect, 6 mm midline shift to left; surrounding hypodense edema; intraventricular extension into right lateral ventricle **Laboratory:** - INR: 3.2 (supratherapeutic on warfarin) - Creatinine: 1.8 mg/dL - Hemoglobin: 12.8 g/dL - Platelet count: 178,000 **Diagnosis:** Spontaneous intracerebral hemorrhage (hypertensive) in setting of supratherapeutic anticoagulation **Treatment:** *Immediate Reversal of Anticoagulation:* - Four-factor prothrombin complex concentrate (4F-PCC) 25 units/kg IV - Vitamin K 10 mg IV - Repeat INR at 30 minutes: 1.3 (reversed) *Blood Pressure Management:* - Target systolic <140 mmHg per INTERACT2 protocol - Nicardipine infusion to achieve target *Neurocritical Care:* - ICU admission - Frequent neurological checks - Head of bed elevated 30 degrees - Seizure prophylaxis (levetiracetam) - DVT prophylaxis with sequential compression devices (no heparin initially) - Neurosurgery consultation (surgical evacuation not indicated for deep hemorrhage without deterioration) *Repeat Imaging:* - CT at 6 hours: Stable hemorrhage volume; no expansion **Clinical Course:** The patient remained stable without hematoma expansion. Over 1 week, his mental status gradually improved. At discharge to rehabilitation on day 10, he was following commands reliably with persistent left hemiparesis (arm 2/5, leg 3/5). Anticoagulation was not restarted; cardiology was consulted for left atrial appendage closure consideration as alternative stroke prevention strategy. **3-Month Outcome:** Modified Rankin Scale 3 (moderate disability, requiring some help with daily activities). Left hemiparesis improved to 3+/5 arm, 4/5 leg. **Clinical Pearl:** Intracerebral hemorrhage in anticoagulated patients requires immediate reversal to prevent hematoma expansion (which occurs in ~30% within the first few hours and predicts worse outcome). 4F-PCC rapidly reverses warfarin effect. Blood pressure should be lowered aggressively (target <140 systolic) to reduce expansion risk. Unlike ischemic stroke where "time is brain" drives reperfusion therapy, ICH management focuses on preventing secondary injury through reversal, blood pressure control, and avoiding complications. The decision about long-term anticoagulation involves balancing stroke prevention (high risk in atrial fibrillation) against recurrent hemorrhage risk. --- ## Clinical Image ![Acute ischemic stroke on DWI MRI](case_01_image.jpg) **Image Description:** Diffusion-weighted MRI (DWI) demonstrating acute ischemic stroke as a region of restricted diffusion (bright signal) in the middle cerebral artery territory. DWI is highly sensitive for acute ischemia, showing changes within minutes of stroke onset, making it the gold standard for confirming acute infarction. **Attribution:** Image from Radiopaedia (https://radiopaedia.org/), Creative Commons Attribution-NonCommercial-ShareAlike 3.0 license.