Endgames Picture quiz

“Brain attack”

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.a3109 (Published 01 April 2009) Cite this as: BMJ 2009;338:a3109
  1. S Macdonald, consultant1,
  2. A Dixit, consultant2,
  3. M G Wyatt, consultant3
  1. 1Interventional Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7TN
  2. 2Stroke Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust
  3. 3Vascular Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust
  1. Correspondence to: M G Wyatt mike.wyatt{at}nuth.nhs.uk

    A 57 year old, right handed man was seen as an emergency after an episode of “flinging” movements of his right arm and leg and slurred speech. He had no visual or sensory symptoms. Examination showed mild right pronator drift, and dysarthria. His symptoms resolved within 45 minutes.

    Blood pressure was 135/75 mm Hg and blood sugar was normal. Electrocardiography confirmed sinus rhythm, and computed tomography of the brain was reported as showing a well defined left cerebellar infarct. Figure 1 shows two images of the origin of the left internal carotid artery.

    Questions

    • 1 What is the patient’s ABCD2 score?

    • 2 In fig 1, what do the upper and lower carotid ultrasound images show? What value of peak systolic velocity is usually quoted as indicating a >70% stenosis, and what is the interpretation of the peak systolic velocity in this figure?

    • 3 What is the likely vascular territory of the patient’s symptoms? Is any intervention indicated? If specific intervention is required for the carotid stenosis, how soon should this be performed?

    • 4 What further imaging would be helpful?

    Answers

    Short answers

    • 1 His ABCD2 score is 3; the cut-off score predicting high risk of very early stroke after “brain attack” is ≥4.1

    • 2 The upper part of fig 2 shows a longitudinal greyscale image of the internal carotid artery with superimposed colour flow (colour map); the lower part shows the recordings of flow velocity (spectral Doppler) over six cardiac cycles. In the upper image, calcified plaque causes posterior acoustic shadowing, which obscures the lumen at the site of the stenosis (white arrow) and mimics an occlusion (yellow arrow). There is turbulent flow with aliasing on both the colour map and on the spectral Doppler. In the lower image, the peak systolic velocity at the proximal internal carotid artery …

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