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A 77 year old right handed man presented after a collapse. He was found to have a dense right sided hemiplegia, with the right arm worse than the right leg and "forehead sparing" facial weakness. He was aphasic, with his gaze preference to the left. His symptoms had been present for 30 minutes and did not improve. No signs of meningism were present. Computed tomography of the head was performed immediately (fig 1 ) and 24 hours after thrombolytic treatment (fig 2 ).
Questions
1 What feature is seen in fig 1?
2 What other stroke signs could be expected on examination?
3 What complication of treatment is evident in fig 2?
4 Using the assessment scale developed by the European Cooperative Acute Stroke Study (ECASS), which category does the scan in fig 2 fit into?
Answers
Short answers
1 Middle cerebral artery dot sign.
2 Eye deviation towards the side of the infarction; contralateral hemianopia; contralateral sensory loss; global aphasia; apraxia; and visual, motor, and sensory neglect.
3 Post-thrombolysis multifocal intraparenchymal haematomas with a midline shift.
4 Parenchymatous haemorrhage category 2 (PH2)-blood in more than 30% of the infarct area, with a substantial space effect.
Long answers
1 Feature on computed tomography
The computed tomography scan performed immediately after presentation (fig 3 ) shows an area of hyperdensity in the distal middle cerebral artery seen in the sylvian fissure on the left. The middle cerebral artery dot sign is an early marker of thromboembolic occlusion of distal middle cerebral artery branches seen in the sylvian fissure. 1
It is important to recognise early signs of stroke given the advent of thrombolysis and the need to deliver recombinant tissue plasminogen activator within three hours. Other more subtle signs of early infarction exist, and can be discreetly assessed using the ASPECT (Alberta stroke program early computed tomography) score. 2 3 Such scoring systems allow more robust assessment of computed tomography scans for stroke and reduce interobserver variability.
2 Other signs
This patient is right handed, so his left hemisphere is dominant. Symptoms of middle cerebral artery stroke include contralateral hemiplegia,...