Different Strokes: A management dilemma

Abstract

Stroke is a common medical emergency resulting from numerous pathophysiological mechanisms and with varied clinical manifestations; as such, the diagnosis of stroke requires diligent clinical assessment. When different stroke syndromes occur in the same patient, it may cause a dilemma in terms of diagnosis and management. This continuing medical education article describes an interesting patient with recurrent neurological events, highlighting the complex pathophysiological processes associated with cerebrovascular syndromes. It offers readers the opportunity to apply their own basic neuroscience knowledge and clinical skills to solve the challenges encountered during the course of diagnosing and treating this patient. Specifically, the article aims to familiarise readers with an approach to diagnosing brainstem strokes and the diverse manifestations of a common stroke syndrome.

Keywords: Cerebral Hemorrhage; Cerebral Small Vessel Disease; Continuing Medical Education; Lacunar Stroke; Stroke.

Figure 1

A: Photograph of a 55-year-old hypertensive woman with left ptosis and a divergent squint. B: Computed tomography scan of the brain showing brainstem and periventricular hypodensities (arrows).

Figure 2

Photograph of a 55-year-old hypertensive woman with left eye-lid ptosis and right-sided hemiparesis.

Figure 3

A: Computed tomography scan of the brain of a 55-year-old hypertensive woman three hours after the onset of right-sided hemiparesis showing left thalamocapsular haemorrhage (arrow). B–E: Magnetic resonance images of the brain two days later showing (B and C) left thalamocapsular intracerebral haemorrhage (arrows), as well as scattered hyperintensities (arrowheads) in the (D) periventricular white matter and (E) brainstem.

Figure 4

A: Susceptibility-weighted magnetic resonance image of the brain of a 55-year-old hypertensive woman two days after the onset of right-sided hemiparesis showing additional hypointensities scattered in the deep ganglionic and periventricular regions and the brainstem (arrow). B: Magnetic resonance angiography showing irregularities of the intracranial arteries, suggestive of atherosclerosis (arrow).