Neurology department PK So in tae Byun sang jun Case Presentation Neurology department PK So in tae Byun sang jun

Identifying Date Name : Lee O O Sex : Female Age : 68

Chief Complaint Rt. side weakness and mild dysarthria for 4 days

Present Illness 2007.4.27 -Sudden onset Rt. side arm and leg weakness has developed - gait disturbance like drunken state and stggering to Rt. side - at same time, mild dysarthria has developed 2007.4.28 - With above mentioned symtom, patient visited local medical center and was diagnosis brain infarction at MRI image 2007.4.30 - With a state of above symtom, patient visited ER in being wheel-chair

Personal History Smoking (-) Alcohol (-) Occupation : (-) Right handedness Height : 150 cm Weight : 58 kg EKG : negative T V1,2,3,4 CXR : mild cardiomegaly abdominal girth : 90cm hip girth : 94cm NIHSS : 3

Past History Hypertension : (+) -diagnosis at DSMC in 2006 and regular medication Diabetes mellitus : (-) At admission Lab test, random glucose level>200 Pulmonary tuberculosis : (-) Migraine : (-) Oral contraceptive agent : (-) Previous cerebrovascular accident history : (+) -2005.4.18 -Rt.side weakness and mild dysarthria delveloped - Lt.pontine infarction diagnosis at DSMC, after then Plavix regular medication Previous illness history : (+) Thyroid cancer in 2005 Operation at kyung-pook university hospital Synthroid regular medication

Family History Hypertension : (-) Diabetes mellitus : (-) Pulmonary tuberculosis : (-) Previous cerebrovascular accident history : (-)

Physical Examination Vital sign -BP 120/80mmHg PR 84/min -RR 20/min BT 36.5℃ G/A : Well developed HEENT : not pale conjunctiva anicteric sclera Lung : CBS s crackle Heart : RHB s murmur Abdomen : soft & flat Extremities : no pitting edema

System review Ears Throat Respiratory Cardiovascular Gastrointestinal otalgia/ear discharge(-/-) Throat sore throat(-) dysphagia(-) Respiratory coughing/sputum/hemoptysis(-/-/-) Cardiovascular chest discomfort(-) palpitation(-) Gastrointestinal abdominal distension/pain (-/-) Genitourinary urgency/frequency/nocturia/hesistancy/disuria(-/-/-/-/-)

Neurologic Examination 1. Mental Status Consciousness level : alert Speech : mild dysarthria Memory : Remote, recent, immediate : intact Orientation : Time, place, person

Neurologic Examination 2. Cranial Nerves I. Olfactory : intact II. V/A : (20/600, 20/200) V/F : intact by confrontation method Fundus : no papilledema & retinal change (-) III.IV.VI EOM : full range Pupil : RRERL c 3mm No spontaneous or gaze evoked nystagmus V. Facial sensation Pain, temperature Touch - decreased pain sensory modality on Rt. hemiface Vibration

Neurologic Examination VII. NLFF (-/-) Forehead wrinkling (+/+) VIII. Hearing difficulty (-/-) Weber test : no lateralization Rinne test : (AC>BC, AC>BC) IX.X. Gag reflex (+/+) Uvular deviation (-) XI. SCM & Trapezius muscle - intact XII. Tongue deviation(-)

Neurologic Examination 3. Motor 1) Tone : normal 2) Power : Pronator sign (+/-) hand grip (4/5) Finger flexion (4/5) extension (4/5) Finger abduction (4/5) adduction (3/5) Wrist flexion (4/5) extension (4/5) Elbow flexion(3/5) extension (3/5) Arm abduction(3/5) adduction (4/5) Hip flexion (3/5) extension (3/5) Knee flexion (3/5) extension (3/5) Ankle dorsiflexion (3/5) plantarflexion (3/5) 3) Muscle bulk : no muscular atrophy

Neurologic Examination 4. Sensory Pain, temperature, touch, vibration, position - intact 5. DTR Brachioradialis jerk (+/+) Biceps jerk(+/+) Triceps jerk (+/+) Patella jerk (++/+) Ankle jerk (++/+) Babinski’s sign (-/-)

Neurologic Examination 6. Cerebellar sign Finger to nose test : impaired on Rt. side due to weakness Heel to knee test : impaired on Rt. side due to weakness Romberg test : unable to check due to Rt. side Stepping gait : unable to check due to Rt. side Tandem gait : unable to check due to Rt. side weakness 7. Gait : ataxic hemiparetic gait

Formulation Neurologic examination Rt.hemiparesis , increased Rt. side patella ,ankle jerk, Precentral gyrus Corticospinal tr Mild dysarthria corticobulbar tract decreased pain sensory modality on Rt. Hemiface Ventroposteromedial Nu. of thalamus Lt. ventral trigeminothalamic tr. Rt. Spinal tr. of trigeminal Nu. Ataxic hemiparesis Lt. thalamocapsular lesion Lt post. Limb of the interanl capsule Lt basis pontis lesion Lt corticospinal tr and corticopontocerebellar tr

Formulation -old age, old CVA risk factor, sudden onset neurologic deficit ->suggest vascular origin -HTN, old age atherosclerotic factor ->suggest stroke -Only Rt. Side weakness and mild dysarthria symtom and reserve cortical function (e.g. congnition, language,visual field……) -> suggest small vessel disease

Impression ◎Rt. Side weakness and mild dysarthria cause R/O Cerebral infartion R/O Lacunar syndrome

Diagnostic Plan Brain MRI & MRA TTE & TCD

Brain MRI (DWI) 07.05.02 Acute Lt. mid basis of pontins infartion

Brain MRA 07.05.02

Diagnosis Lt. pontine infarction

Therapeutic Plan Antiplatelet drug hydration Bed rest and Conservative manage

Disease Report Lacunar infarction

Definition small deep cerebral infarcts caused by disease of the penetrating arteries small size (less than 1.5cm diameter), deep cerebral or brain stem location on CT or MRI occur most frequently in the basal ganglia and internal capsule, thalamus, corona radiata, and pons.

Risk factors and pathogenesis lipohyalinosis -encountered in hypertensives microatheroma -atherosclerosis of penetrating arteries, single most frequent cause of lacunar infarcts, seen in normotensive Hypertesion Diabetes mellitus Smoking Embolism

Clinical features many lacunar infarts are asyptomatic. a gradual or stepwise onset with transient ischemic attacks or a progressive or fluctuating course, which may reflect hypoperfusion distal to a stenosed penetrating artery. Recurrent transient pure motor hemiparesis presenting as crescendo trasient ischemic attacks – reffered to as the capsular warning syndrome ; high risk of stroke within the first 30 days and early sign of basilar artery occlusion.

Classic Lacunar Syndromes Pure motor hemiparesis - most frequent posterior limb of the internal capsule, basis pontis, cerebral peduncle, medullary pyramid. Ataxic hemiparesis - cerebellar limb ataxia and ipsilateral hemiparesis. posterior limb of the internal capsule, basis pontis, corona radiata. Homolateral ataxia and crural paresis Hypesthetic ataxic hemiparesis Dysarthria-clumsy hand syndrome Dysarthria-facial paresis syndrome Pure sensory stroke - posterior ventral thalamus, brain stem Sensorimotor stroke -posterior internal capsule, brain stem infarcts involving the pons, midbrain, medulla.

Diagnostic investigations CT MRI (diffusion-weighted imaging) ECG Cerebral angiography

Management Control of known risk factors - hypertension, smoking, diabetes mellitus Antiplatelet agents