# Clinical Cases: Stroke and Cerebrovascular Disease

## Case 1: Acute Left MCA Stroke - Thrombectomy Candidate

### Patient Demographics
- **Age:** 72 years
- **Sex:** Female
- **Occupation:** Retired teacher

### Chief Complaint
"She can't move her right side and isn't making sense."

### History of Present Illness
Patient was last seen normal at 6:00 AM by her husband. At 8:00 AM, he found her in bed with right-sided weakness and speaking nonsensically. EMS was called and she arrived at the ED at 8:45 AM. Past medical history includes hypertension, type 2 diabetes, and hyperlipidemia. She takes lisinopril, metformin, and atorvastatin.

### Neurological Examination Findings

**Mental Status:**
- Awake but not following commands
- Global aphasia - no meaningful speech output, does not follow commands
- Eyes open spontaneously

**Cranial Nerves:**
- Right gaze preference (eyes deviated to left)
- Right homonymous hemianopia to threat
- Right lower facial droop (UMN pattern)
- Dysarthria

**Motor Examination:**
- Right upper extremity: 0/5 (flaccid plegia)
- Right lower extremity: 1/5
- Left side: Moves spontaneously, antigravity strength

**Sensory Examination:**
- Does not respond to noxious stimuli on right
- Withdraws to pain on left

**Reflexes:**
- Right: 3+ with Babinski positive
- Left: 2+ with flexor plantar response

**NIHSS Score:** 19

### Localization
**Lesion Location:** Left MCA territory (large vessel occlusion)
- Global aphasia (Broca's + Wernicke's = left hemisphere)
- Right hemiplegia (left motor cortex)
- Right gaze deviation toward lesion (left frontal eye fields)
- Right hemianopia (left optic radiations)
- Dense contralateral sensory loss

### Neuro Workup
- **CT Head without contrast:** Hyperdense left MCA sign, subtle loss of insular ribbon
- **CT Angiography:** Left M1 occlusion with good collaterals
- **CT Perfusion:**
  - Core infarct: 15 mL
  - Penumbra: 85 mL (Target mismatch - favorable for intervention)
- **ASPECTS Score:** 7
- **Labs:** Glucose 156, INR 1.0, Cr 0.9, platelets 245K

### Diagnosis
**Acute left MCA ischemic stroke** with large vessel occlusion (LVO) - thrombectomy candidate

### Management
**Acute Management:**
1. IV alteplase initiated (within 4.5-hour window from last known well)
2. Emergent mechanical thrombectomy - TICI 3 recanalization achieved
3. BP goal: <180/105 during first 24 hours post-tPA
4. Admit to Neuro ICU

**Post-Procedure Care:**
1. Repeat CT head at 24 hours - no hemorrhagic transformation
2. Started aspirin 325 mg at 24 hours
3. Telemetry monitoring - atrial fibrillation detected
4. Echocardiogram: Left atrial enlargement, no thrombus
5. Anticoagulation with apixaban started day 4

**Rehabilitation:**
1. Speech therapy for aphasia
2. PT/OT for right hemiparesis
3. Dysphagia evaluation - modified diet
4. Acute rehab placement

### Clinical Image
![Left MCA Stroke](case_01_image.jpg)

**Image Description:** CT angiography demonstrating occlusion of the left M1 segment of the middle cerebral artery with absent distal filling.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Jeremy Jones. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/left-mca-stroke-1

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## Case 2: Wallenberg Syndrome (Lateral Medullary Stroke)

### Patient Demographics
- **Age:** 58 years
- **Sex:** Male
- **Occupation:** Truck driver

### Chief Complaint
"I feel like I'm spinning, and I can't swallow properly."

### History of Present Illness
Sudden onset of severe vertigo, nausea, and vomiting while driving. He pulled over and noticed difficulty swallowing his saliva. His voice became hoarse. He also felt numbness on the left side of his face and the right side of his body. He has a 40-pack-year smoking history and untreated hypertension.

### Neurological Examination Findings

**Mental Status:**
- Alert and oriented x3
- Speech: Hoarse, dysarthric

**Cranial Nerves:**
- **CN V:** Decreased sensation left face (all divisions)
- **CN VIII:** Horizontal nystagmus, fast phase to right; no hearing loss
- **CN IX/X:** Absent left gag reflex, uvula deviates to right, hoarse voice
- **CN XI:** Left shoulder shrug weakness
- **CN XII:** Tongue midline

**Motor Examination:**
- 5/5 strength throughout all extremities

**Sensory Examination:**
- Decreased pain/temperature: Left face, right arm, right trunk, right leg
- Vibration and proprioception intact throughout

**Reflexes:**
- 2+ symmetric throughout
- Plantar responses flexor bilaterally

**Coordination:**
- Left finger-to-nose: Mild dysmetria (ipsilateral cerebellar signs)
- Left heel-to-shin: Mild ataxia
- Right side: Normal

**Gait:**
- Ataxic, tends to fall to the left
- Romberg positive

**Other:**
- Left Horner syndrome: Ptosis, miosis, anhidrosis

### Localization
**Lesion Location:** Left lateral medulla (Wallenberg Syndrome)
- Ipsilateral facial sensory loss (descending trigeminal tract)
- Contralateral body pain/temperature loss (spinothalamic tract)
- Ipsilateral Horner syndrome (descending sympathetics)
- Dysphagia/hoarseness (nucleus ambiguus - CN IX, X)
- Ipsilateral cerebellar signs (inferior cerebellar peduncle)
- Vertigo/nystagmus (vestibular nuclei)

**Vascular territory:** Posterior inferior cerebellar artery (PICA) or vertebral artery

### Neuro Workup
- **CT Head:** No hemorrhage, no acute changes
- **MRI Brain (DWI):** Restricted diffusion in left lateral medulla
- **MRA Head/Neck:** Left vertebral artery dissection with high-grade stenosis
- **CT Angiography:** Confirms left vertebral dissection
- **Echocardiogram:** Normal, no PFO

### Diagnosis
**Left lateral medullary infarction (Wallenberg Syndrome)** secondary to left vertebral artery dissection

### Management
**Acute:**
1. Aspirin 325 mg initially, then anticoagulation given dissection
2. NPO - failed bedside swallow evaluation
3. Speech therapy for swallowing rehabilitation
4. IV fluids and NGT for nutrition

**Secondary Prevention:**
1. Anticoagulation with heparin bridge to warfarin (INR goal 2-3) for 3-6 months
2. Repeat imaging at 3 months to assess dissection healing
3. Smoking cessation counseling
4. Blood pressure control
5. Statin therapy

**Prognosis:** Generally good; dysphagia may persist for weeks to months

### Clinical Image
![Lateral Medullary Infarct](case_02_image.jpg)

**Image Description:** MRI DWI sequence showing restricted diffusion in the left lateral medulla, consistent with acute infarction (Wallenberg syndrome).

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/wallenberg-syndrome-2

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## Case 3: Intracerebral Hemorrhage with Herniation

### Patient Demographics
- **Age:** 65 years
- **Sex:** Male
- **Occupation:** Retired factory worker

### Chief Complaint
"He suddenly collapsed and won't wake up."

### History of Present Illness
Patient was watching television when he suddenly complained of the worst headache of his life, then became unresponsive within minutes. Family called 911. He has a history of poorly controlled hypertension (often runs 180s/100s systolic) and medication non-compliance. He takes amlodipine and lisinopril "sometimes."

### Neurological Examination Findings

**Mental Status:**
- GCS: 6 (E1 V2 M3)
- No eye opening, incomprehensible sounds, withdraws to pain
- Not following commands

**Cranial Nerves:**
- Left pupil: 6 mm, fixed, non-reactive (concerning for uncal herniation)
- Right pupil: 3 mm, reactive
- Corneal reflexes: Absent left, present right
- No oculocephalic reflex (doll's eyes absent)

**Motor Examination:**
- Decorticate posturing on left with stimulation
- Right side: Extensor posturing
- No spontaneous movement

**Sensory Examination:**
- Withdraws to central pain only

**Reflexes:**
- 3+ bilateral
- Bilateral Babinski positive

**Other:**
- Blood pressure: 220/120 mmHg
- Signs of increased ICP: Cushing reflex (hypertension, bradycardia)

### Localization
**Lesion Location:** Left basal ganglia/putaminal hemorrhage with mass effect
- Contralateral hemiplegia (left internal capsule/basal ganglia)
- Fixed dilated left pupil (uncal herniation compressing CN III)
- Decreased consciousness (ascending reticular activating system compression)
- Bilateral extensor posturing (brainstem dysfunction)

### Neuro Workup
- **CT Head without contrast:** Large left putaminal hemorrhage (60 mL), 12 mm midline shift, effacement of left lateral ventricle, early uncal herniation
- **ICH Score:** 4 (poor prognosis)
- **Labs:** INR 1.0, platelets 180K, Cr 1.8
- **CTA:** No underlying vascular malformation

### Diagnosis
**Hypertensive left putaminal intracerebral hemorrhage** with uncal herniation

### Management
**Emergent Interventions:**
1. Secure airway - intubation for GCS <8
2. Blood pressure reduction: IV nicardipine to target SBP 140-160
3. Hyperosmolar therapy: Mannitol 1 g/kg IV, then q6h; or hypertonic saline
4. Head of bed 30 degrees
5. Neurosurgery consultation for possible hematoma evacuation

**ICU Management:**
1. External ventricular drain (EVD) placement for ICP monitoring and CSF drainage
2. Goal ICP <20 mmHg, CPP >60 mmHg
3. Seizure prophylaxis with levetiracetam
4. Reversal agents if on anticoagulation (not applicable here)
5. Fever control - normothermia

**Goals of Care:**
1. Family meeting regarding prognosis (ICH score 4 = ~97% mortality at 30 days)
2. Discussion of comfort measures vs. aggressive intervention
3. Palliative care consultation

### Clinical Image
![Putaminal Hemorrhage](case_03_image.jpg)

**Image Description:** Non-contrast CT head demonstrating a large left putaminal hemorrhage with significant mass effect, midline shift, and compression of the left lateral ventricle.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/hypertensive-basal-ganglia-haemorrhage