Acute Aphasia And Right-Sided Weakness


Consult Page

89F with a left MCA syndrome and perfusion mismatch, consult for thrombectomy

Initial Imaging

Figure 25.1, An axial head CT without contrast shows a hyperdense left MCA sign (arrow) and hypodensity in the left lentiform nucleus (arrow heads), concerning for acute left MCA occlusion. Vessels on head CT without contrast are typically isodense, and a hyperdensity within a vessel indicates a hyperacute clot or a calcification. The right insular hypodensity seen is likely sequela from an old stroke.

Walking Thoughts

  • Have the ABC’s been appropriately addressed?

  • When was the patient last seen normal?

  • Has the stroke team evaluated the patient?

  • Was tissue plasminogen activator (tPA) given?

  • What is the patient’s NIH stroke scale score?

  • Is the patient on any antiplatelet or anticoagulant medications?

  • What imaging has been performed? Is there a large vessel occlusion? Does perfusion imaging need to be obtained?

  • Does the patient need a mechanical thrombectomy?

  • Does the patient have an advanced directive in place? Who is her healthcare agent?

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.

Figure 25.2, Coronal head CTA with maximal intensity projections (A) demonstrates occlusion of the left M1 segment of the MCA. CT perfusion shows a significantly larger area of decreased perfusion (dark blue) on cerebral blood flow imaging (B) compared to the smaller area of core infarct (dark blue) seen on cerebral blood volume imaging (C) concerning for ischemic penumbra.

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