A 75-Year-Old Woman with a Hemispheric Stroke

A 75-year-old right-handed woman presented with a two-day history of symptoms suggestive of a right hemispheric stroke (slurred speech and left facial and left arm weakness). She had no previous cerebrovascular symptoms, such as symptoms of a previous transient ischaemic attack or amaurosis fugax (loss of vision in one eye due to a temporary lack of blood fl ow to the retina). Past medical history included long-standing hypertension and chronic obstructive pulmonary disease. She was on amlodipine, 10 mg once daily, and salbutamol and fl uticasone inhalers. On examination, the patient had a Glasgow Coma Score of 15, she was apyrexial, her pulse rate was regular, at 80 per min, and her blood pressure was 176/99 mm Hg. There was no cardiac murmur or carotid bruits. She had left-sided weakness. Brain imaging is necessary for two main reasons. The fi rst is to exclude a brain haemorrhage (responsible for 25% of all strokes [1]); against this diagnosis was the absence of headache and a normal Glasgow Coma Score. The second is to rule out a brain tumour. Computed tomography (CT) brain scanning on admission showed two areas of low density within the right cerebral hemisphere, one in the right parietal lobe and one in the posterior right frontal lobe (Figure 1), most likely ischaemic in nature. Small low-density lesions consistent with lacunar infarcts were also seen in both basal ganglia, the most prominent ones seen within the left basal ganglia. There was also marked frontal atrophy, and atrophy of the brain stem structures. The CT scan showed no evidence of haemorrhagic transformation of the infarct, a condition that is a contraindication for anticoagulation. Routine blood tests (full blood count, urea and electrolytes, and clotting), an electrocardiogram, and a chest X ray were performed before the CT brain scan. The electrocardiogram showed no arrhythmia or changes suggestive of an old or new myocardial infarction. The normal electrocardiogram raised the possibility of embolisation from a large artery (such as the right carotid artery or the aortic arch), rather than from the heart. A carotid ultrasound showed a calcifi ed, haemodynamically signifi cant plaque at the right carotid bifurcation. A similar lesion seen at the left carotid bifurcation was not haemodynamically signifi cant. Carotid angiogram showed a tight stenosis of the distal right common carotid artery (Figure 2), and occlusion of the left internal carotid artery. Bendrofl uazide, 2.5 mg once daily, and …