- Email: [email protected]
Worsening clinical features in a patient with right middle cerebral artery territory stroke
Journal of Clinical Neuroscience 68 (2019) 304–305
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images
Worsening clinical features in a patient with right middle cerebral artery territory stroke Vijay K. Sharma a,⇑, Arvind K. Sinha b a b
Yong Loo Lin School of Medicine, National University of Singapore and Division of Neurology, National University Hospital, Singapore Department of Diagnostic Imaging, National University Hospital, Singapore
a r t i c l e
i n f o
Article history: Received 24 April 2019 Accepted 7 July 2019
a b s t r a c t We describe a case with acute ischemic stroke in the right MCA territory. He developed secondary deterioration for which no obvious cause could be found. He underwent FDG-PET for evaluating carotid plaque inflammation as part of a research study, which revealed considerable hypometabolism in the left cerebellar hemisphere-responsible for the neurological deterioration. This phenomenon is often called ‘crossed cerebellar diaschisis. Various imaging findings are presented. Ó 2019 Elsevier Ltd. All rights reserved.
A 68 years old man presented after 2-hours of left sided weakness of sudden-onset. His cardiovascular risk factors included hypertension, dyslipidemia and ischemic heart disease. Upon arrival, he was fully conscious, orientated, had an irregularly irregular pulse (95 beats/minute) and blood pressure 164/96 mmHg. Neurological examination revealed mild dysarthria, left visual neglect and left-sided weakness (power Medical Research Council MRC grade 2). National Institute of Health Stroke Scale (NIHSS) score was 15 points. Computerised tomography (CT) of the brain did not reveal any intracranial bleeding. However, CT angiography revealed an acute occlusion of the mid-M1 segment of the right middle cerebral artery (MCA). Treatment with intravenous tissue plasminogen activator (TPA) was initiated. Continuous monitoring of right MCA with transcranial Doppler demonstrated complete recanalization of the right MCA at 26 min after TPA bolus, associated with rapid clinical improvement. NIHSS at the end of TPA infusion was 5 points. CT angiography on day-2 confirmed complete recanalization of the right MCA. He continued to improve and could walk (power MRC grade 4 in left lower limb and 2 in upper limb) with assistance at the time of transfer to the community hospital for rehabilitative therapy on day-5. However, he was transferred back to our tertiary hospital 3-days later due to gradual neurological deterioration. Upon arrival, he was severely dysarthric, showed flaccid left hemiplegia
DOI of answer: https://doi.org/10.1016/j.jocn.2019.07.060
⇑ Corresponding author at: Division of Neurology, Department of Medicine, 1E, Kent Ridge Road, National University Health System, Singapore 119228, Singapore. E-mail address: [email protected] (V.K. Sharma). https://doi.org/10.1016/j.jocn.2019.07.034 0967-5868/Ó 2019 Elsevier Ltd. All rights reserved.
(power MRC grade 0 in both upper and lower limbs) and gaze-evoked nystagmus. Magnetic resonance imaging of the brain revealed the previous right subcortical infarct (Fig. 1A). There was neither any new stroke, including the posterior circulation (Fig. 1B) nor any intracranial vascular occlusion (Fig. 1C). He was afebrile and no evidence of sepsis or metabolic abnormalities was noted. Since a large heterogeneous plaque was seen at the right carotid bulb, he was recruited into a research study and underwent positron emission tomography (PET)/CT using flurodeoxyglucose. Although, the study aimed at evaluating carotid plaque inflammation, some part of the brain was also exposed (Fig. 1D, E). 1. Question – What was the cause of new flaccid left hemiplegia and cerebellar signs in the patient? A. B. C. D. E.
Scar epilepsy New diffusion negative left cerebellar stroke Critical illness polyneuropathy Crossed cerebellar diaschisis Severe hypokalemia
Answer on page 350.
V.K. Sharma, A.K. Sinha / Journal of Clinical Neuroscience 68 (2019) 304–305
305
Fig. 1. Neuroimaging findings. Magnetic resonance imaging of the brain on day-8 after acute stroke revealed an acute infarction in the right middle cerebral artery territory (A). No abnormal signals are noted in the posterior circulation (B). CT angiography revealed normal vertebrobasilar system (C). Extensive areas of cerebral hypometabolism were noted in the right middle cerebral artery territory (D) in addition to the surprising finding of left cerebellar hypometabolism (E).
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images
Worsening clinical features in a patient with right middle cerebral artery territory stroke Vijay K. Sharma a,⇑, Arvind K. Sinha b a b
Yong Loo Lin School of Medicine, National University of Singapore and Division of Neurology, National University Hospital, Singapore Department of Diagnostic Imaging, National University Hospital, Singapore
a r t i c l e
i n f o
Article history: Received 24 April 2019 Accepted 7 July 2019
a b s t r a c t We describe a case with acute ischemic stroke in the right MCA territory. He developed secondary deterioration for which no obvious cause could be found. He underwent FDG-PET for evaluating carotid plaque inflammation as part of a research study, which revealed considerable hypometabolism in the left cerebellar hemisphere-responsible for the neurological deterioration. This phenomenon is often called ‘crossed cerebellar diaschisis. Various imaging findings are presented. Ó 2019 Elsevier Ltd. All rights reserved.
A 68 years old man presented after 2-hours of left sided weakness of sudden-onset. His cardiovascular risk factors included hypertension, dyslipidemia and ischemic heart disease. Upon arrival, he was fully conscious, orientated, had an irregularly irregular pulse (95 beats/minute) and blood pressure 164/96 mmHg. Neurological examination revealed mild dysarthria, left visual neglect and left-sided weakness (power Medical Research Council MRC grade 2). National Institute of Health Stroke Scale (NIHSS) score was 15 points. Computerised tomography (CT) of the brain did not reveal any intracranial bleeding. However, CT angiography revealed an acute occlusion of the mid-M1 segment of the right middle cerebral artery (MCA). Treatment with intravenous tissue plasminogen activator (TPA) was initiated. Continuous monitoring of right MCA with transcranial Doppler demonstrated complete recanalization of the right MCA at 26 min after TPA bolus, associated with rapid clinical improvement. NIHSS at the end of TPA infusion was 5 points. CT angiography on day-2 confirmed complete recanalization of the right MCA. He continued to improve and could walk (power MRC grade 4 in left lower limb and 2 in upper limb) with assistance at the time of transfer to the community hospital for rehabilitative therapy on day-5. However, he was transferred back to our tertiary hospital 3-days later due to gradual neurological deterioration. Upon arrival, he was severely dysarthric, showed flaccid left hemiplegia
DOI of answer: https://doi.org/10.1016/j.jocn.2019.07.060
⇑ Corresponding author at: Division of Neurology, Department of Medicine, 1E, Kent Ridge Road, National University Health System, Singapore 119228, Singapore. E-mail address: [email protected] (V.K. Sharma). https://doi.org/10.1016/j.jocn.2019.07.034 0967-5868/Ó 2019 Elsevier Ltd. All rights reserved.
(power MRC grade 0 in both upper and lower limbs) and gaze-evoked nystagmus. Magnetic resonance imaging of the brain revealed the previous right subcortical infarct (Fig. 1A). There was neither any new stroke, including the posterior circulation (Fig. 1B) nor any intracranial vascular occlusion (Fig. 1C). He was afebrile and no evidence of sepsis or metabolic abnormalities was noted. Since a large heterogeneous plaque was seen at the right carotid bulb, he was recruited into a research study and underwent positron emission tomography (PET)/CT using flurodeoxyglucose. Although, the study aimed at evaluating carotid plaque inflammation, some part of the brain was also exposed (Fig. 1D, E). 1. Question – What was the cause of new flaccid left hemiplegia and cerebellar signs in the patient? A. B. C. D. E.
Scar epilepsy New diffusion negative left cerebellar stroke Critical illness polyneuropathy Crossed cerebellar diaschisis Severe hypokalemia
Answer on page 350.
V.K. Sharma, A.K. Sinha / Journal of Clinical Neuroscience 68 (2019) 304–305
305
Fig. 1. Neuroimaging findings. Magnetic resonance imaging of the brain on day-8 after acute stroke revealed an acute infarction in the right middle cerebral artery territory (A). No abnormal signals are noted in the posterior circulation (B). CT angiography revealed normal vertebrobasilar system (C). Extensive areas of cerebral hypometabolism were noted in the right middle cerebral artery territory (D) in addition to the surprising finding of left cerebellar hypometabolism (E).