A 56-year-old man with a past medical history of hypertension and diabetes mellitus is hospitalized after sustaining a mild concussion following a motor vehicle accident. His daily medications include aspirin, metformin, and lisinopril. He has smoked one pack of cigarettes daily for 20 years. He does not drink alcohol. He is married and works as an accountant. His family history is significant for coronary artery disease and diabetes mellitus.
His blood pressure is 143/95 mm Hg and pulse is 90/min with regular rhythm. His general physical and neurological examinations are unremarkable.
An MRI of the brain without contrast reveals a chronic infarct in the right basal ganglia without any evidence of intracranial bleeding.
This patient is at the highest risk for which of the following?

Question

A 56-year-old man with a past medical history of hypertension and diabetes mellitus is hospitalized after sustaining a mild concussion following a motor vehicle accident.  His daily medications include aspirin, metformin, and lisinopril.  He has smoked one pack of cigarettes daily for 20 years.  He does not drink alcohol.  He is married and works as an accountant.  His family history is significant for coronary artery disease and diabetes mellitus.
His blood pressure is 143/95 mm Hg and pulse is 90/min with regular rhythm.  His general physical and neurological examinations are unremarkable.
An MRI of the brain without contrast reveals a chronic infarct in the right basal ganglia without any evidence of intracranial bleeding.
This patient is at the highest risk for which of the following?

Quizplus · Accepted Answer

This patient's brain MRI shows a silent, chronic lacunar infarct in the right basal ganglia related to his hypertension and diabetes mellitus. Given his vascular risk factors, he is at risk of having additional ischemic events. These events can accumulate over time and cause significant damage to the surrounding white matter tracts and subcortical grey matter, which are essential for proper cognitive function. One study found that patients with silent infarcts with positive brain imaging have double the risk of developing dementia over the subsequent 5 years, compared to normal controls with normal brain imaging. Multiple silent infarcts were associated with an even higher risk than single infarcts. Therefore, this patient is at risk for developing vascular (Binswanger's) dementia in the future. (Choice B) Migraine headaches are a common primary headache disorder typically afflicting patients between the ages of 15-50 years. Migraine headaches (especially those associated with prolonged negative aura) can lead to migrainous cerebral infarction from headache-induced changes in vascular tone or caliber. However, vascular risk factors and stroke have not been linked to a higher future risk of developing migraine headaches. (Choice C) Multiple sclerosis is an autoimmune demyelinating disease that predominantly affects the central white matter of the brain and spinal cord. Vascular risk factors and stroke have not been linked with an increased future risk of developing multiple sclerosis. (Choice D) Normal pressure hydrocephalus is a disorder characterized by ataxia, dementia, and urinary incontinence. This condition develops as a result of impaired cerebrospinal fluid absorption at the arachnoid granulations and has no causal relationship with ischemic events in the brain. (Choice E) The risk of developing seizures following an acute stroke is approximately 5-10% if the stroke involves the cortex. Subcortical strokes typically do not increase the risk of seizures. Severe concussions (e.g., associated with loss of consciousness or amnesia) can lead to a high risk of developing epilepsy later in life. However, this patient only had a mild concussion, and therefore has a low risk for epilepsy. Educational objective: Elderly people with silent brain infarcts have an increased risk of developing dementia than those without such lesions. __________ References: Silent brain infarcts and the risk of dementia and cognitive decline. (http://www.ncbi.nlm.nih.gov/pubmed/12660385)

A 56-Year-Old Man with a Past Medical History of Hypertension