5 Stroke Cases Not to Miss

Editor's note: In the following slideshow, Dr. Helmi Lutsep presents her perspective on 5 brief stroke cases representing actual patient encounters. Neuroimaging findings are presented along with recommended management approaches based on up-to-date evidence and clinical trial findings.

Patient 1

This patient is a woman in her early 50s who presented with recurrent episodes of right arm weakness. Cerebral angiogram revealed a high-grade calcified stenosis of the proximal right internal carotid artery.

Patient 1 (cont)

Cerebral angiogram shows a widely patent right internal carotid artery after stenting. Because the patient had symptomatic high-grade stenosis, she was enrolled in the CREST trial and was randomly assigned to the stenting arm. She has had no recurrent symptoms over the 6 years since the stent was placed. Although CREST did not show an interaction with the primary endpoint (including periprocedural events plus ipsilateral strokes up to 4 years) for sex, a preplanned analysis of the periprocedural endpoint alone showed more outcome events for stenting than for carotid endarterectomy (CEA) in women but not in men. The sex of the patient is one potential risk factor that must be weighed when selecting the most appropriate treatment for a patient.

Patient 2

This computed tomography angiogram (CTA) shows a high-grade stenosis of the proximal right middle cerebral artery. The patient is a woman in her 70s, who presented with left face and arm weakness.

Patient 2 (cont)

Cerebral angiography confirms the high-grade right M1 stenosis. The patient was enrolled in the SAMMPRIS trial and was randomly assigned to intensive medical therapy alone. She is receiving aggressive treatment to keep her blood pressure less than 140/90 mm Hg and she is being treated with rosuvastatin to lower her low-density lipoprotein level to less than 70 mg/dL. She has had no recurrent events over the 2 years since she was enrolled. The SAMMPRIS trial revealed that aggressive medical management was superior to percutaneous transluminal angioplasty and stenting with the use of the Wingspan stent system. This patient's management course would not have changed outside of the trial. 

Patient 3

Slurred speech, poor balance, and difficulty picking up his right leg developed suddenly in a 62-year-old man. He had right hand and foot sensory symptoms 7 years before that, as well as slowing of his thought processes over that time. He only had rare headaches. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) was confirmed by genetic testing. This diffusion-weighted MRI reveals an area of diffusion restriction within the left corona radiate consistent with a new stroke.

Patient 3 (cont)

Fluid-attenuated inversion recovery (FLAIR) MRI shows hyperintensity that involves the external capsule. The patient also had some anterior temporal pole involvement that is often seen in patients with CADASIL.

Patient 3 (cont)

This MRI shows diffuse periventricular hyperintensities typically found in patients with CADASIL. Although it has not been assessed in randomized clinical trials, the use of an antiplatelet agent and risk factor modification are generally recommended for stroke prevention in patients with CADASIL. Counseling and therapies for migraine prophylaxis and mood disorders may also be helpful.

Patient 4

Left face and arm numbness and tingling and incoordination of the left arm developed in a 57-year-old woman. This recurred 3 times over a period of 12 hours and finally persisted. The diffusion-weighted image revealed a right thalamic infarct. She received risk factor management and aspirin. Symptoms that stutter are a common feature of lacunar strokes. For ongoing stroke prevention, such patients should receive a single antiplatelet agent. The data safety monitoring board for the SPS3 trial in patients with lacunar strokes terminated the antiplatelet combination therapy portion of the trial because of futility and the occurrence of more bleeding events in patients treated with clopidogrel plus aspirin than in those on aspirin alone.

Patient 5

The patient is a 40-year-old woman with previously normal development in whom holocephalic headache, behavioral changes, and paraphasias developed. MRI obtained 4 days after symptom onset demonstrated an abnormality in the right temporal lobe seen best on T2-weighted imaging (shown). There was no diffusion restriction or enhancement with contrast.

Patient 5 (cont)

Three weeks later, the patient began experiencing auditory hallucinations of washing machine noises and seizures with left hand shaking. The T2-weighted MRI revealed that the lesion was now less apparent in the anterior right temporal lobe but had progressed to other brain areas. Although she improved initially, 6 months later headaches, aphasia, and disinhibition developed. The patient was diagnosed with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) after genetic testing. L-arginine may decrease the frequency and severity of the stroke-like episodes; however, other treatments remain unproven and the course of MELAS is progressive.

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