Endgames Picture Quiz

Recurrent episodes of hemiparesis and aphasia

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4674 (Published 20 October 2010) Cite this as: BMJ 2010;341:c4674
  1. R Nandhagopal, consultant neurologist1,
  2. Abdullah Al-Asmi, senior consultant neurologist1,
  3. G R Arunodaya, associate professor of neurology1,
  4. P C Jacob, assistant professor of neurology1,
  5. Faisal Al-Azri, senior consultant radiologist2
  1. 1Department of Medicine, College of Medicine and Health Sciences, Al-Khod, Muscat, Oman
  2. 2Department of Radiology and Molecular Imaging, College of Medicine and Health Sciences, Al-Khod, Muscat, Oman
  1. Correspondence to: R Nandhagopal, Department of Medicine, College of Medicine and Health Sciences, PO Box 35, SQU Al-Khod, Zip 123, Muscat, Oman rnandagopal{at}yahoo.com

An 81 year old man with hypertension and diabetes mellitus presented to the accident and emergency service seven hours after acute onset of right hemiparesis and expressive aphasia. Seven months previously, he had experienced similar symptoms that had partially improved over the subsequent few weeks.

On examination, he was in sinus rhythm. Neurologically, he showed right facial weakness (involving the lower half of his face), right hemiparesis with a power of 4 to 4+ out of 5, right sided pyramidal signs, and non-fluent aphasia. Plain computerised tomography of the brain performed at hospital admission showed an old hypodensity in the right frontal subcortical area.

Subsequently, the patient underwent cranial magnetic resonance imaging (fig 1) and a computed tomography angiogram (fig 2) because the blood vessels in the magnetic resonance angiogram were obscured by motion artefacts that precluded proper interpretation. Cardiac evaluation (electrocardiography and echocardiography) showed mild left ventricular hypertrophy, but the patient had no intramural clots, wall motion abnormalities, or arrhythmia.

Fig 1 Axial diffusion weighted magnetic resonance image of the brain (A) and the corresponding apparent diffusion coefficient map (B)

Fig 2 Coronal computed tomography angiogram of the neck vessels (A, B, C, and D), with corresponding axial segments of the distal cervical portion of the left internal carotid artery indicated by long arrows (E). Sagittal image of the cervical part of the left internal carotid artery (F). Lt, left side

Questions

  • 1 What abnormalities are observed in the magnetic resonance image?

  • 2 What findings are seen in the computed tomography angiogram of the neck vessels?

  • 3 What is the cause of this patient’s recurrent neurological problems?

  • 4 How would you treat this patient?

  • 5 What measures would you use to prevent recurrence of the neurological symptoms?

Answers

1 What abnormalities are observed in the magnetic resonance image?

Short answer

The diffusion weighted magnetic resonance image of the brain (diffusion sensitivity …

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