A 50-year-old woman is brought to the emergency department after suddenly experiencing right upper and lower extremity weakness while jogging on a treadmill. Her weakness gradually worsened over the next hour, and she had severe headache, nausea, and vomiting. The patient has a history of chronic hypertension but stopped taking antihypertensives several months ago. She does not use tobacco but drinks 1 or 2 glasses of wine on weekends. Blood pressure is 230/112 mm Hg and pulse is 76/min and regular. On physical examination, the patient is stuporous and responds to painful stimuli only. There is right hemiplegia, right hemisensory loss, and leftward deviation of the eyes. Which of the following is the most likely diagnosis?

Question

A 50-year-old woman is brought to the emergency department after suddenly experiencing right upper and lower extremity weakness while jogging on a treadmill.  Her weakness gradually worsened over the next hour, and she had severe headache, nausea, and vomiting.  The patient has a history of chronic hypertension but stopped taking antihypertensives several months ago.  She does not use tobacco but drinks 1 or 2 glasses of wine on weekends.  Blood pressure is 230/112 mm Hg and pulse is 76/min and regular.  On physical examination, the patient is stuporous and responds to painful stimuli only.  There is right hemiplegia, right hemisensory loss, and leftward deviation of the eyes.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5a8_a9fb_bc81_d7c7c87b266e_MD0003_00 This patient with underlying hypertension had acute-onset focal neurologic deficits during a period of increased activity. The deficits worsened over the next hour, and then she developed symptoms concerning for increased intracranial pressure (eg, headache, nausea/vomiting), which progressed to affect her consciousness. This progression suggests a stroke due to intraparenchymal brain hemorrhage, commonly caused by hypertension. Hypertensive hemorrhages typically present with sudden focal neurologic deficits that gradually worsen over minutes to hours. They generally involve the same small, penetrating arteries responsible for lacunar stroke. The most frequently affected locations include the basal ganglia (putamen), cerebellar nuclei, thalamus, and pons. Putaminal hemorrhage almost always involves the adjacent internal capsule. This leads to contralateral hemiparesis and hemianesthesia (due to disruption of the corticospinal and somatosensory fibers in the posterior limb) and conjugate gaze deviation toward the side of the lesion (due to damage of frontal eye field efferents in the anterior limb), as in this patient with leftward eye deviation (ie, toward the lesion). Cerebellar hemorrhage most commonly presents with occipital headache, nausea/vomiting, dizziness, and cerebellar signs (eg, ataxia, dysmetria); there is usually no hemiparesis (Choice A). In addition to the specific focal deficits, the time course helps distinguish between different stroke types. (Choice B) Embolic or thrombotic occlusion of the proximal middle cerebral artery can cause cerebral ischemic infarction with contralateral hemiparesis, hemianesthesia, and conjugate gaze deviation toward the lesion. Thrombotic stroke symptoms often have a "stuttering" course with periods of worsening and improvement; embolic stroke symptoms are typically maximal at onset. This patient's sudden neurologic deficits that gradually worsened and led to signs of increased intracranial pressure are more consistent with hemorrhage. (Choice C) Medial medullary syndrome occurs due to branch occlusion of the vertebral or anterior spinal artery. It presents with contralateral paralysis of the arm and leg (lateral corticospinal tract), contralateral loss of position sense (dorsal column medial lemniscus), and tongue deviation toward the lesion (hypoglossal nerve). (Choice E) Spontaneous subarachnoid hemorrhage is another type of hemorrhagic stroke. It typically occurs due to rupture of a saccular hemorrhage and presents initially with a severe headache that reaches maximal intensity within an hour. Signs of meningeal irritation (eg, neck stiffness) typically develop; focal neurologic deficits are uncommon. Educational objective: Strokes due to intracerebral hemorrhage often have focal neurologic deficits that progressively worsen over minutes to hours, followed by features of increased intracranial pressure. The basal ganglia (putamen) are common sites, and deficits often include contralateral hemiparesis, contralateral sensory loss, and conjugate gaze deviation toward the side of the lesion. References: Putaminal hemorrhages. (http://www.ncbi.nlm.nih.gov/pubmed/22377882)

A 50-Year-Old Woman Is Brought to the Emergency Department After