A 71-year-old woman is brought to the emergency department due to not feeling well and worsening right leg weakness. The patient had a stroke 2 years ago and has mild residual right leg weakness. Over the last 2 days, her weakness has gotten worse compared to her baseline, and she can hardly ambulate with a cane. The patient has a history of persistent atrial fibrillation and takes daily warfarin.
Her temperature is 38.3 C (101 F), blood pressure is 150/90 mm Hg, pulse is 94/min, and respirations are 14/min. Pulse oximetry shows 97% on room air. Neurologic examination shows spastic right lower extremity weakness and hyperreflexia. A noncontrast head CT reveals an old infarct in the left anterior cerebral artery territory.
Laboratory results are as follows:

Which of the following is the most likely explanation for this patient's symptoms?

Question

A 71-year-old woman is brought to the emergency department due to not feeling well and worsening right leg weakness.  The patient had a stroke 2 years ago and has mild residual right leg weakness.  Over the last 2 days, her weakness has gotten worse compared to her baseline, and she can hardly ambulate with a cane.  The patient has a history of persistent atrial fibrillation and takes daily warfarin.
Her temperature is 38.3 C (101 F), blood pressure is 150/90 mm Hg, pulse is 94/min, and respirations are 14/min.  Pulse oximetry shows 97% on room air.  Neurologic examination shows spastic right lower extremity weakness and hyperreflexia.  A noncontrast head CT reveals an old infarct in the left anterior cerebral artery territory.
Laboratory results are as follows:

Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

This patient presents with worsening of her previous stroke symptoms due to a urinary tract infection. Acute exacerbations of prior neurologic deficits may happen in conjunction with acute infection or metabolic derangement and can sometimes be difficult to distinguish from a new ischemic event. This patient's current neurologic exacerbation is referable to the same vascular territory that was previously affected (eg, left anterior cerebral artery infarction with contralateral lower extremity hemiparesis) and occurred in the setting of an acute infection; therefore, a new cardioembolic event is less likely, especially with a therapeutic International Normalized Ratio on warfarin (Choice E). Diffusion-weighted brain MRI can always be considered if any uncertainty exists or if diagnostic confirmation is required. (Choice A) Acute spinal cord compression (eg, from spontaneous epidural hematoma or epidural abscess) is unlikely in the absence of back pain. (Choice C) L5 radiculopathy is a result of nerve root irritation, and symptoms follow a dermatomal pattern. It usually presents with lower back pain radiating down the ipsilateral leg and can be associated with foot drop and numbness along the anterolateral leg. This patient's focal upper motor neuron signs (eg, spasticity, hemiparesis, hyperreflexia) are consistent with an old cerebral infarction, not radiculopathy. dermatomal pattern (Choice D) Normal pressure hydrocephalus initially presents with ataxia, followed by dementia and urinary incontinence. Neuroimaging should demonstrate dilated ventricles, not an old infarction. Educational objective: Acute exacerbations of prior neurologic deficits may occur in conjunction with acute infection or metabolic derangement and can sometimes be difficult to distinguish from a new ischemic event. Diffusion-weighted brain MRI can be considered if uncertainty exists or if diagnostic confirmation is required. __________ References: Use of DWI-only MR protocol for screening stroke mimics. (http://www.ncbi.nlm.nih.gov/pubmed/23498367)

A 71-Year-Old Woman Is Brought to the Emergency Department Due