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Acute Onset Left Hemiparesis


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72M presents with L sided weakness, stroke team activated, R ICA stenosis.

Initial Imaging

Figure 32.1, Head CT without contrast (A) demonstrates no completed large-territory infarcts and no acute hemorrhage. Head CT perfusion study demonstrates reduced blood flow (B) in the entire right MCA territory without reduced total blood volume (C) to suggest completed infarction.

Figure 32.2, A coronal view of a head CTA demonstrates no right MCA stenosis or occlusion (A). CTA of the neck demonstrates significant stenosis (red arrow) in the proximal right ICA (B). This is measured to be 95% stenosis via NASCET criteria (1-A/B) (C).

Walking Thoughts

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    Have the patient’s ABCs been addressed?

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    What is the patient’s neurological exam? When was the patient last seen normal?

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    Does the patient have an acute stroke? Has neurology evaluated the patient?

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    What is the cause of stroke? Does the patient have internal carotid artery (ICA) stenosis?

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    Does the patient have other risk factors for stroke (e.g. atrial fibrillation)?

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    What imaging has been obtained for this patient?

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    What is the degree of ICA stenosis quantitatively? Is there tandem stenosis?

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    Does the patient need a mechanical thrombectomy?

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    Does the patient take anticoagulant or antiplatelet medications?

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    Does the patient have a significant cardiac history or prior stroke history that might affect the modality of treatment?

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