1. Case discussion. Vs 李宜中,R1 林玫瑩

2. General data: Name: 賴錦 x Age:52 years old Occupation: 鐵工廠老闆 Admission date:2006/5/30.

3. C.C: Sudden onset of slurred speech, numbness and weakness over left limbs in the evening of 95/5/29.

4. Present illness: Hypertension with medical control for half year. 95/5/17: intermittent left hand numbness and dizziness - 署立苗栗醫院 - left hemiparesis,- suspect TIA-5/17:brain CT: brain atrophy without significant abnormality.-S/P hydration- symptom improved-discharged on 5/22. After discharge :intermittent dizziness + left hand numbness.

5. 95/5/29: sudden onset of dizziness +left hand numbness +left limb weakness several minutes - 署立苗栗醫院. Brain CT:no significant abnormality. Conscious drowsiness – transferred to our ER: NE: Left hemiparesis, conscious drowsiness, poor response to deep pain over left limbs and left homonymous hemianopia.

6. Past history:HTN with medical control for half year. History of TIA in 5/17. Smoking:1PPD for 35 years, not quit. Alcohol consumption:social drinking for 35 years.

7. NE: Conscious:clear, orientated, memory: normal, abstract thinking:normal, attention: normal. Mild dysarthria. Crainal nerve :light reflex:+/+,left side hononynous hemianopia.Corneal reflex:+/-.left side central type facial palsy.tongue deviated to the left.

8. Motor exam:muscle tone: hypotonia over left limbs.muscle strength:right U/L:5/5,left U/L:0/0. Sensory exam: impaired pinprink test over left V2+V3, left limbs.Joint position: impaired over left limbs. Reflex: right U/L:++/+, left lower U/L:++/+.Barbinski sign: both plantarflexion. Cerebellar sign:right side : FNF, RAM and HKS.left side can ’ t evaluate.

9. PE: HEENT: no pale conjunctiva. Neck: no LAP. Chest: clear breathing sound. Heart : RHB. Extremity: no pitting edema. No body weight loss.

10. Impression: Acute cerebral infarction,suspect right MCA territory. Hypertension.

11. Hospitalization. N/S hydration +tapal+Gina. Due to young onset: 6/6:MRA

12. MRI: Conclusion: 1. Occlusion or thrombotic right ICA under collateral circulation came from fine stenotic ACoA and right PCoA forright MCA territory with insufficiency and infarction under gyral pattern petechiae and enhancement with mass effect. 2. Multiple separated enhanced nodules in right side cerebral sulci and beneath right temporal horn. R/O multiple seeding tumor or metastasis, significance?

13. CXR: No active lung lesion. Abdomen sonography:Mild fatty liver and coarse echoes.Small GB with polyp. No body weight loss.No LAP.

14. Final diagnosis: Acute cerebral infarction, right F-T-P region due to right side ICA occlusion. Suspect multiple tumor seeding or tumor metastasis.