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  1. Daniel A Jones, specialist trainee 2, cardiology1,
  2. Fiona Walker, consultant cardiologist2,
  3. Neha R Chopra, foundation year 21,
  4. Walter Serino, consultant cardiologist1,
  5. Farhad Huwez, consultant physician1
  1. 1Basildon and Thurrock NHS Trust, Basildon, Essex SS16 5NL
  2. 2The Heart Hospital, London W1G 8PH
  1. Correspondence to: DA Jones danieljones{at}doctors.org.uk

    A 41 year old woman was admitted with sudden onset of severe headache followed by collapse and decreased consciousness.

    She had a history of frequent migraines but was not taking regular drugs. She was a non-smoker with no history of recreational drug use.

    On admission her Glasgow coma scale was 7/15 (E1 V1 M5). Her pupils were unequal but reactive. Examination of her peripheral nervous system showed increased tone in all four limbs with brisk reflexes. Plantar reflexes were equivocal. Her blood pressure was 150/80 mm Hg, pulse was regular at 44 beats/min, and oxygen saturation was 99% on 10 l/min. Cardiovascular examination was normal. A respiratory examination was normal.

    The patient was intubated. Computed tomography of the head excluded intracranial haemorrhage.

    A lumbar puncture was performed, and cerebrospinal fluid was sent for analysis; it showed white blood cell count 0×106/l (reference range 0-5 (all lymphocytes, no neutrophils)), red blood cell count 23×106/l (0-10), protein 0.3 g/l (0.2-0.4), glucose 3.8 mmol/l (3.3-4.4 or about two thirds of the blood glucose concentration), and no xanthochromia. Magnetic resonance imaging (MRI) of the brain was performed one week later (fig 1⇓).

    Transoesophageal echocardiography was performed three weeks later (fig 2⇓).

    Fig 1 Magnetic resonance imaging of the brain

    Fig 2 Transoesophageal echocardiogram with contrast

    Questions

    • 1 What abnormality can be seen on magnetic resonance imaging of the brain, and what is the diagnosis?

    • 2 What abnormality is seen on transoesophageal echocardiography?

    • 3 How would you manage this patient acutely?

    • 4 What other investigations are needed to confirm the cause?

    • 5 How would you manage this patient in the long term?

    Answers

    Short answers

    • 1 Magnetic resonance imaging shows bilateral thalamic infarcts with a larger lesion on the left thalamic nucleus than on the right (fig 3⇓). A few …

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