Hyperdense MCA Sign
Answer: D
This man’s presentation is consistent with right middle cerebral artery stroke. The initial differential diagnosis included both hemorrhagic (young person, acute onset during exertion, headache) and embolic events (profound hemiplegia). Immediate neuroimaging is essential to determine the presence or absence of hemorrhage.
His CT shows a dense middle cerebral artery sign, indicative of an embolic event. Although a review of the indications and contraindications is well beyond the scope of this discussion, a young, healthy patient with a profound neurologic deficit with an identifiable clot in the MCA is, among the studied sub-groups, a relatively favorable tPA candidate than found in other presentations.
There are many caveats to tPA administration but one hard stop is rapid resolution or improvement of signs and symptoms (C).
Although atraumatic subarachnoid hemorrhage was initially on the differential diagnosis, CT findings are consistent with an embolic event (A). Reasonable active blood pressure control is more of an issue in hemorrhagic stroke (B). Management of blood pressure in embolic stroke is more lenient, to allow for higher blood pressures with the intention of optimizing cerebral perfusion pressure.
This patient presented with a profound right MCA stroke and initially was a reasonable tPA candidate; however, now with resolution of symptoms, the clock is “reset”. He should be monitored closely in the intensive care unit for possible return of symptoms; in the meantime, the risk to benefit ratio favors an antiplatelet agent such as aspirin in the acute setting.
This man’s presentation and dramatic resolution of signs and symptoms warrant discussion. The etiologies of stroke in the young and the old are traditionally disparate; however, as young people experience increasing morbidity and accumulation of risk factors, the lines between typical pediatric/young adult disease and older adult disease become blurred.
Causes of stroke in children and young adults are varied: cardiac (congenital heart disease), hematologic (sickle cell disease, prothrombotic states such as protein deficiency, malignancy), vascular (connective tissue disorder, dissection, post-infectious, Kawasaki disease, moyamoya, arterial venous malformation), metabolic (Menkes disease, MELAS), and toxicologic (cocaine, methmaphetamines).
Causes of stroke in adults are more commonly associated with risk factors such as long-standing hypertension, smoking, diabetes, and hypercholesterolemia.
The main branch point in diagnosis and management for all age groups is determination of embolic/thrombotic (“bland”) stroke versus hemorrhagic.
This patient will require a thorough inpatient work-up, bridging both pediatric/young adult etiologies and traditionally older adult etiologies.
References
American Heart Association. Guidelines for the Early Management of Adults With Ischemic Stroke : A Guideline From Cardiology Council, Cardiovascular Radiology and Intervention Council, and the the American Heart Association/ American Stroke Association Stroke Council. Stroke. 2007;38:1655-1711.
American Heart Association. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals. Stroke. 2010;41:2108-2129.
American Heart Association. Management of Stroke in Infants and Children: A Scientific Statement From a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39:2644-2691.
This man’s presentation is consistent with right middle cerebral artery stroke. The initial differential diagnosis included both hemorrhagic (young person, acute onset during exertion, headache) and embolic events (profound hemiplegia). Immediate neuroimaging is essential to determine the presence or absence of hemorrhage.
His CT shows a dense middle cerebral artery sign, indicative of an embolic event. Although a review of the indications and contraindications is well beyond the scope of this discussion, a young, healthy patient with a profound neurologic deficit with an identifiable clot in the MCA is, among the studied sub-groups, a relatively favorable tPA candidate than found in other presentations.
There are many caveats to tPA administration but one hard stop is rapid resolution or improvement of signs and symptoms (C).
Although atraumatic subarachnoid hemorrhage was initially on the differential diagnosis, CT findings are consistent with an embolic event (A). Reasonable active blood pressure control is more of an issue in hemorrhagic stroke (B). Management of blood pressure in embolic stroke is more lenient, to allow for higher blood pressures with the intention of optimizing cerebral perfusion pressure.
This patient presented with a profound right MCA stroke and initially was a reasonable tPA candidate; however, now with resolution of symptoms, the clock is “reset”. He should be monitored closely in the intensive care unit for possible return of symptoms; in the meantime, the risk to benefit ratio favors an antiplatelet agent such as aspirin in the acute setting.
This man’s presentation and dramatic resolution of signs and symptoms warrant discussion. The etiologies of stroke in the young and the old are traditionally disparate; however, as young people experience increasing morbidity and accumulation of risk factors, the lines between typical pediatric/young adult disease and older adult disease become blurred.
Causes of stroke in children and young adults are varied: cardiac (congenital heart disease), hematologic (sickle cell disease, prothrombotic states such as protein deficiency, malignancy), vascular (connective tissue disorder, dissection, post-infectious, Kawasaki disease, moyamoya, arterial venous malformation), metabolic (Menkes disease, MELAS), and toxicologic (cocaine, methmaphetamines).
Causes of stroke in adults are more commonly associated with risk factors such as long-standing hypertension, smoking, diabetes, and hypercholesterolemia.
The main branch point in diagnosis and management for all age groups is determination of embolic/thrombotic (“bland”) stroke versus hemorrhagic.
This patient will require a thorough inpatient work-up, bridging both pediatric/young adult etiologies and traditionally older adult etiologies.
References
American Heart Association. Guidelines for the Early Management of Adults With Ischemic Stroke : A Guideline From Cardiology Council, Cardiovascular Radiology and Intervention Council, and the the American Heart Association/ American Stroke Association Stroke Council. Stroke. 2007;38:1655-1711.
American Heart Association. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals. Stroke. 2010;41:2108-2129.
American Heart Association. Management of Stroke in Infants and Children: A Scientific Statement From a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39:2644-2691.