A 40-year-old woman is brought to the emergency department after an hour of sudden-onset, severe headache and progressive right-sided weakness. She has no chronic medical conditions and takes no medications. Temperature is 38.5 C (101.3 F), blood pressure is 170/100 mm Hg, and pulse is 110/min and regular. The pupils are 5 mm and reactive to light. The neck is supple. Right-sided facial weakness and slurred speech are noted. There is weakness and decreased pinprick sensation in the right upper and lower extremities. Cardiopulmonary examination is normal with no murmurs or gallops. The abdomen is soft, nontender, and without organomegaly. A noncontrast CT scan of the head reveals a left thalamic hemorrhage with no midline shift. Electrocardiogram is normal except sinus tachycardia. Which of the following is most likely to reveal the underlying etiology of this patient's symptoms?

Question

A 40-year-old woman is brought to the emergency department after an hour of sudden-onset, severe headache and progressive right-sided weakness.  She has no chronic medical conditions and takes no medications.  Temperature is 38.5 C (101.3 F), blood pressure is 170/100 mm Hg, and pulse is 110/min and regular.  The pupils are 5 mm and reactive to light.  The neck is supple.  Right-sided facial weakness and slurred speech are noted.  There is weakness and decreased pinprick sensation in the right upper and lower extremities.  Cardiopulmonary examination is normal with no murmurs or gallops.  The abdomen is soft, nontender, and without organomegaly.  A noncontrast CT scan of the head reveals a left thalamic hemorrhage with no midline shift.  Electrocardiogram is normal except sinus tachycardia.  Which of the following is most likely to reveal the underlying etiology of this patient's symptoms?

Quizplus · Accepted Answer

Explanation: This patient with headache, progressively worsening right-sided weakness, and hemisensory loss has an intracranial hemorrhage (ICH), with neuroimaging showing a left thalamic hemorrhage. Once neuroimaging confirms ICH, treatment focuses on managing hypertension, normalizing intracranial pressure, and preventing further bleeding. In addition, the etiology of hemorrhage should be determined. Several features of this patient's presentation should raise suspicion for cocaine use as the underlying cause: Young age: Most patients who sustain stroke are age >60. Absence of typical risk factors: Chronic hypertension, notably absent in this patient, is the most common underlying cause of ICH. Sympathetic activation: In addition to acute hypertension, this patient has tachycardia, mydriasis, and hyperthermia (due to cocaine-induced vasoconstriction preventing heat dissipation). Location: Cocaine-induced ICH is most commonly seen in subcortical locations (eg, thalamus) and has a higher risk of associated intraventricular hemorrhage. Therefore, a urine toxicology screen is one of the tests recommended in the evaluation of patients with ICH. (Choice A) Carotid artery stenosis would lead to ischemic, rather than hemorrhagic, stroke (due to either decreased blood flow through the carotids or thrombus formation in the stenotic area). (Choice B) Echocardiography can identify infective endocarditis or left atrial myxoma, both of which can cause stroke. However, in such cases, stroke is thrombotic/embolic (eg, maximal symptoms at onset) rather than hemorrhagic (eg, typically progressive symptoms). In addition, although endocarditis can cause fever, it is usually associated with a murmur and is often characterized by several days of systemic manifestations (eg, malaise, weight loss). (Choice C) Lumbar puncture (LP) can diagnose meningitis, which can cause headache and fever and is sometimes complicated by focal bleeding and focal neurologic manifestations. Although LP can be considered in this patient if the toxicology screen is negative, the absence of neck stiffness, the presence of sympathetic activation (eg, mydriasis), and the focal bleed in the thalamus make cocaine use more likely than meningitis. (Choice D) Coagulation studies (eg, prothrombin time, activated partial thromboplastin time) are obtained in patients with ICH to evaluate for underlying coagulopathy. However, thrombin time is only recommended in patients with ICH who are taking direct oral anticoagulants (eg, rivaroxaban). Educational objective: Cocaine use can precipitate intracranial hemorrhage and should be suspected when stroke occurs in a subcortical location and/or in young patients with associated sympathetic activation or an absence of typical risk factors.

A 40-Year-Old Woman Is Brought to the Emergency Department After