A 72-year-old woman with a past medical history of hypertension, type 2 diabetes mellitus, and coronary artery disease suddenly drops her fork while having dinner with her family. Her speech becomes slurred and she develops right-sided weakness. She then has an episode of vomiting. An hour later, while being evaluated in the hospital, she is stuporous, does not respond to verbal stimuli, and grimaces to pain. Her blood pressure is 185/107 mm Hg and pulse is 55/min. The Babinski reflex is upgoing on the right side. Her fingerstick glucose is 365 mg/dL. Additional laboratory testing and imaging studies are ordered. Which of the following is the most likely cause of this patient's current condition?

Question

A 72-year-old woman with a past medical history of hypertension, type 2 diabetes mellitus, and coronary artery disease suddenly drops her fork while having dinner with her family.  Her speech becomes slurred and she develops right-sided weakness.  She then has an episode of vomiting.  An hour later, while being evaluated in the hospital, she is stuporous, does not respond to verbal stimuli, and grimaces to pain.  Her blood pressure is 185/107 mm Hg and pulse is 55/min.  The Babinski reflex is upgoing on the right side.  Her fingerstick glucose is 365 mg/dL.  Additional laboratory testing and imaging studies are ordered.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d164_9714_bc81_45f1a84d2f40_MD0003_00 This patient has acute onset of unilateral right-sided weakness and slurred speech, which is consistent with acute stroke. Stroke characteristics can indicate both the location of the focal brain lesion and possible etiology (Table). This patient's clinical findings suggest a left cerebral hemisphere lesion (particularly the motor cortex and Broca's area). Hypertensive intracerebral hemorrhage (ICH) generally evolves over a course of minutes to hours. Patients initially present with focal neurologic symptoms (eg, hemiplegia, hemiparesis, hemisensory disturbances). These are quickly followed by findings suggestive of increased intracranial pressure (eg, vomiting, headache, bradycardia [as part of Cushing triad of hypertension, bradycardia, irregular respirations], decreased alertness). In contrast, patients with subarachnoid hemorrhage (SAH) complain of severe headache at the onset and usually do not have focal neurologic findings. Brain CT imaging confirms ICH or SAH and excludes other causes. (Choice A) Cardiogenic emboli usually occur in patients with arrhythmias, hypercoagulability, or other conditions that cause embolic formations (eg, endocarditis). When the source of embolus is the heart or aorta, multiple infarcts occur within different vascular territories, producing patchy neurologic findings. In embolic stroke, symptom onset is abrupt and usually maximal at the start and sometimes results in rapid recovery. (Choice B) Carotid artery atherosclerosis can produce stroke by flow limitation or embolization. Symptoms result from ipsilateral ocular and cerebral hemisphere ischemia. Examination can show carotid bruit. Large hemispheric strokes can produce cerebral edema over several hours to days but very rarely cause such severe symptoms so early. (Choice C) Hyperosmotic hyperglycemic state can present in type 2 diabetics with altered mental status and/or neurologic deficits. However, symptoms usually do not start until blood glucose >600 mg/dL (more often >1000 mg/dL). This patient's hyperglycemia is likely due to her postprandial state and/or the stress of intracranial hemorrhage. (Choice E) Lacunar strokes can also occur in hypertensive patients but tend to present with severe focal symptoms depending on the affected area. These infarcts are quite small and would not be expected to cause the rapidly worsening global neurologic symptoms (eg, vomiting, stupor, bradycardia) seen in this patient. Educational objective: Hypertensive intracerebral hemorrhages occur most commonly in the basal ganglia, thalamus, pons, and cerebellum. Patients tend to present initially with focal symptoms but can rapidly progress to signs of elevated intracranial pressure. Brain CT confirms hemorrhage and excludes other causes. References: Classification of stroke subtypes. (http://www.ncbi.nlm.nih.gov/pubmed/19342825) Intracranial hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/22167847)

A 72-Year-Old Woman with a Past Medical History of Hypertension