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

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

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

4. Present Illness
-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
- With above mentioned symtom, patient visited local medical
center and was diagnosis brain infarction at MRI image
- With a state of above symtom, patient visited ER in
being wheel-chair

5. 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

6. 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 : (+)
-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

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

8. 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

9. 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(-/-/-/-/-)

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

11. 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

12. 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(-)

13. 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

14. 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 (-/-)

15. 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

16. 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

17. 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

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

19. Diagnostic Plan
Brain MRI & MRA
TTE & TCD

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

21. Brain MRA

22. Diagnosis
Lt. pontine infarction

23. Therapeutic Plan Antiplatelet drug hydration
Bed rest and Conservative manage

24. Disease Report
Lacunar infarction

25. 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.

26. 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

27. 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.

28. 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.

29. Diagnostic investigationsCT
MRI (diffusion-weighted imaging)
ECG
Cerebral angiography

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