Weekly Case Study: Case 13

48 year-old Afro American man develops early morning headache and dizziness. This improves by mid-morning. He goes to PCP and his blood pressure is 180/100 mm Hg. He is prescribed Metoprolol and hydro-diuril. He takes this for one month but medication makes him sleepy, impotent and he has to go to the bathroom frequently; therefore he stops the medication. His headache and dizziness resolve. He remains asymptomatic until two months later when he awakens unable to use his left hand and trips over his left leg. He goes to work but by mid-morning he is not improved and his employer insists he see his physician who refers him to a neurologist.

NE

dysarthria
left hemiparesis
left sided Babinski
left central facial weakness

PE

BP 200/110    P 80    afebrile
left carotid bruit
hypertensive retinopathy
neck - supple

Images

Questions:

  1. What is most likely mechanism of initial neurological symptoms (headache, dizziness) and new focal neurological symptoms?

  2. What is the significance of left carotid bruit? Should the cause of bruit be investigated?

  3. Does CT scan accompanying this case show the most likely causal lesion?

  4. What would MRI most likely show?

  5. What would angiogram be expected to show?

  6. Outline - secondary stroke prevention strategy.
  7. Should heparin or thrombolytic medication be used?
  8. Should BP be acutely lowered?

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Films C-13 (3) - Revised 6/21/2005