Case Study 2: Couldn’t Raise Left Hand

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 2: Joe—Couldn't raise left hand and arm

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A 72-year-old male is brought into the ER by ambulance after he could not pick up his mug of coffee using his left hand. His wife said he tried to pick up the mug, but couldn’t raise his hand and arm off the table. She also noticed that the left side of his face looked “droopy,” and thought he might be having a stroke. His past medical history is notable for mild hypercholesterolemia, hypertension, and stable angina.

Question

Initial imaging is likely to reveal a finding in which location of the patient’s brain?

The patient is demonstrating left-sided upper extremity weakness as well as left-sided facial droop. This is consistent with a lesion on the contralateral side of the brain (R) and in the MCA territory. 

Localize a stroke

Localizing a stroke involves careful physical examination combined with imaging findings. It is a much bigger topic than we can cover in this single module.

Overview of common stroke findings, by location:

  • Majority of strokes are supratentorial s/sx of “FAST” (facial droop, arm weakness, speech disturbance, time). 
UpToDate.
Reproduced with permission from: Netter, FH, Caplan, LR. Cerebrovascular Disease, Section III, Plate 8. In: The Netter Collection of Medical Illustrations, Vol. 1, Nervous System, Part II, Neurologic and Neuromuscular Disorders, Netter, FH, Jones, HR, Dingle, RV (Eds), MediMedia USA, Inc 1986. Copyright ©1986 Elsevier. Graphic 69630 Version 1.0 © 2021 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Less common (think vertebral arteries):

  • s/sx may include diplopia, dysphagia, bulbar palsies, unilateral loss of coordination and even altered consciousness (due to brainstem involvement).
  • Aphasia.
  • Right hemiparesis.
  • Right hemianopia.
  • Left hemispatial neglect.
  • Left hemiparesis.
  • Left hemianopia.
  • Anterior cerebral artery = more likely to have contralateral lower extremity weakness/numbness.
  • Middle cerebral artery = more likely to have contralateral upper extremity weakness/numbness (including contralateral facial droop).

Movement disorders

Image credits

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