Acute Aphasia And Right-Sided Weakness

History of Present Illness

An 89 year old female with a history of prior strokes, hypertension, and atrial fibrillation, notably not on any anticoagulants or antiplatelets, presents to the emergency department (ED) after being found down in her assisted living facility. She was last seen well eating dinner approximately 10 hours prior. At baseline per her daughter, she is able to independently carry out the majority of her activities of daily living. She was initially triaged in the ED as a trauma patient due a presumed fall. However, on examination, she was noted to have a left gaze deviation and hemiparesis of the right side with aphasia.

The stroke team was activated, and she was taken immediately to the CT scanner. Head CT without contrast showed a hyperdense left middle cerebral artery (MCA) sign and subtle hypodensity in the left MCA territory ( Figure 25.1 ). Given concern for a large vessel occlusion, a CT angiogram (CTA) of the head and neck was performed, which showed an abrupt cut-off at the left proximal MCA (M1 or horizontal segment). CT perfusion (CTP) demonstrated marked perfusion deficit with relatively preserved cerebral blood volume ( Figure 25.2 ). Given the large penumbra and relatively small core infarct, neurosurgery was consulted for possible thrombectomy. The stroke neurology team assessed the patient, giving her a NIH stroke scale score of 20. Her Alberta stroke program early CT (ASPECTS) score based on initial head CT was 9.