Chapter

Case 31

Sarah Pendlebury, Ursula Schulz, Aneil Malhotra and Peter M. Rothwell

in Oxford Case Histories in TIA and Stroke

Published on behalf of Oxford University Press

Published in print January 2012 | ISBN: 9780199539345
Published online November 2012 | e-ISBN: 9780191753251 | DOI: http://dx.doi.org/10.1093/med/9780199539345.003.0191

Series: Oxford Case Histories

Case 31

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A 75-year-old woman, who was previously well, presented with a sudden-onset severe left-sided headache, which she likened to being hit with a brick. This was associated with non-specific dizziness, a tingling sensation in the left hand and the left side of the face, and a slight left facial droop. Symptoms were severe for 10 minutes, after which the patient was left with a generalized moderately severe headache and feeling ‘woozy’. On admission to the emergency department, her blood pressure was 210/90mmHg. She had no focal neurological deficit. She was investigated for a possible SAH. A CT brain scan was normal, but the subsequent lumbar puncture was unhelpful because of a traumatic tap. A CT angiogram showed a possible aneurysm of the right ICA, and an intra-arterial angiogram was arranged for further investigation. The angiogram confirmed a 2mm ectasia of the carotid artery in the siphon which was of no therapeutic consequence. It also showed widespread segmental stenoses involving all the vascular territories in the major intracranial arteries as well as the distal more peripheral branches (Fig. 31.1) A subsequent MRI brain scan and MRA two days later confirmed these findings and also showed multiple small infarcts in all vascular territories, some microhaemorrhages, and moderate small vessel disease (Figs 31.2 and 31.3). The patient remained in hospital while she was investigated. Her headache settled over a few days, and there was no recurrence of her severe initial headache. She developed no neurological deficit. Her blood pressure proved difficult to control, but was around 150/90mmHg on discharge, following treatment with amlodipine and a thiazide diuretic.

Chapter.  1731 words.  Illustrated.

Subjects: Neurology

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