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A 22-year-old man is evaluated in the emergency department 8 hours after the sudden onset of moderate neck pain followed by vertigo, ataxia, slurred speech, and difficulty swallowing. His medical history is unremarkable and he is not taking any medications. Physical examination shows left ptosis, anisocoria with the left pupil smaller than the right, nystagmus, left-sided dysmetria, and decreased pain and temperature sensation on the left side of the face and right side of the body. CT scan of the brain is normal.
Which of the following is the most appropriate next step in the evaluation of this patient?
A Repeat noncontrast CT scan of the brain in 24 hours
B Carotid ultrasound
C MRI and magnetic resonance angiography of the brain and neck
D Lumbar puncture
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is it A
Involvement of posterior inferior cerebellar artery.(wallenberg syndrome)
CT SCANS are negative within the first 18hrs.so we should repeat the CT scan.
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BUT IT ALL STARTED AFTER NECK PAIN
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AND WHAT WLD A REPEAT CT SHOW?
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CAROTID DOESNT EXPLAIN PTOSIS .5TH N SYMPTOMS, ATAXIA. ONLY PICA EXPLAINS ALL THIS.
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repeat CT to distinguish bt hemorrhagic and ischemic stroke
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tabish
what is the answer
is it repeat CT or MRI
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Correct Answer = C)
Key Points
* Vertebral artery dissection typically presents with neck or head pain, Horner's syndrome, dysarthria, dysphagia, decreased pain and temperature sensation, dysmetria, ataxia, and vertigo.
* Magnetic resonance angiography is a sensitive diagnostic test for vertebral artery dissection as a cause of stroke.
This patient has an ischemic stroke (cerebral infarction). The symptoms and signs involve multiple lower cranial nerves (dysphagia, dysarthria), crossed sensory deficits, and cerebellar ataxia, which suggest a left lateral medullary localization, possibly also involving the left cerebellum. The sudden onset of symptoms suggests that stroke is the cause. The normal CT rules out a parenchymal intracerebral hemorrhage, which would be unlikely in the medulla. Blood is supplied to this area by the posterior inferior cerebellar artery, a major branch of the vertebral artery. In a previously healthy young person, the less common causes of stroke must be considered, such as vertebral artery dissection, which often occurs spontaneously without trauma or typical vascular risk factors. Typical symptoms of vertebral dissection include neck or posterior head pain, Horner's syndrome (ptosis and miosis), dysarthria, dysphagia, decreased pain and temperature sensation of the face and contralateral body, dysmetria, ataxia, and vertigo. Magnetic resonance angiography is an excellent tool in diagnosing dissection. Noncontrast CT scan in 24 hours will only reveal the evolving stroke, not its cause. Carotid ultrasound studies do not reliably characterize abnormalities in the vertebral artery other than reversal of flow. Lumbar puncture is used to evaluate suspected subarachnoid hemorrhage in a patient who has a severe headache with a normal CT scan, but such localized medullary symptoms would be atypical for subarachnoid hemorrhage.
Bibliography
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