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Endgames Picture quiz

Stroke quiz

BMJ 2009; 339 doi: (Published 02 September 2009) Cite this as: BMJ 2009;339:b3343
  1. Asif Atik Mazumder, registrar, geriatric medicine1,
  2. George Anthony Pope, clinical fellow, stroke medicine1
  1. 1Department of Stroke Medicine, King’s College Hospital, London SE1 6AW
  1. Correspondence to: A A Mazumder asifmaz{at}

    A 77 year old right handed man presented after a collapse. He was found to have a dense right sided hemiplegia, with the right arm worse than the right leg and “forehead sparing” facial weakness. He was aphasic, with his gaze preference to the left. His symptoms had been present for 30 minutes and did not improve. No signs of meningism were present. Computed tomography of the head was performed immediately (fig 1) and 24 hours after thrombolytic treatment (fig 2).

    Fig 1 Computed tomogram of the head at presentation

    Fig 2 Computed tomogram of the head 24 hours after thrombolytic treatment


    • 1 What feature is seen in fig 1?

    • 2 What other stroke signs could be expected on examination?

    • 3 What complication of treatment is evident in fig 2?

    • 4 Using the assessment scale developed by the European Cooperative Acute Stroke Study (ECASS), which category does the scan in fig 2 fit into?


    Short answers

    • 1 Middle cerebral artery dot sign.

    • 2 Eye deviation towards the side of the infarction; contralateral hemianopia; contralateral sensory loss; global aphasia; apraxia; and visual, motor, and sensory neglect.

    • 3 Post-thrombolysis multifocal intraparenchymal haematomas with a midline shift.

    • 4 Parenchymatous …

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