Age: 47 years
Gender: Female
Occupation: Staff nurse
Working Diagnosis: Transient ischemic attack
HISTORY
The patient was completely well until she suddenly developed slurred speech one morning while preparing to go to work. She noted weakness of her right arm and hand at the same time. There was no headache. The symptoms persisted for 1 hour, and her husband brought her to the local hospital.
On examination the patient was in sinus rhythm and had a normal cardiovascular examination. She had mild dysarthria but no drooling, and appreciable but mild weakness in elbow extension, wrist dorsiflexion, and intrinsic hand muscles. No other objective abnormalities were found.
She was admitted to the hospital. A cerebral magnetic resonance angiography suggested thrombosis of the left middle cerebral artery. A duplex ultrasound of her carotid arteries was normal. Her strength gradually returned and she was discharged home. Warfarin therapy was started.
She has a history of migraine with a visual aura that had been treated with ergonovine only when severe. She was on no other medication. She has had no other medical problems including hypertension or diabetes.
She was a chronic smoker.
PHYSICAL EXAMINATION
BP 120/70, HR 76 bpm, oxygen saturation 99%
Height: 165 cm, weight 61 kg, BSA 1.67 m 2
Surgical scars: None
Neck veins: 2 cm above the sternal angle, with a normal waveform
Lungs/chest: Normal
Heart: Regular rhythm, normal first and second heart sounds, no murmur identified. No abnormalities by palpation.
Abdomen: Normal
Central nervous system: Normal cranial nerves, normal sensory system examination, with very mild residual weakness of right side. Speech was normal, as were her fundi.
LABORATORY DATA
| Hemoglobin | 13.1 g/dL (13.0–17.0) |
| Hematocrit/PCV | 39% (36–46) |
| MCV | 93 fL (83–99) |
| Platelet count | 393 × 10 9 /L (150–400) |
| Sodium | 138 mmol/L (134–145) |
| Potassium | 4.0 mmol/L (3.5–5.2) |
| Creatinine | 0.9 mg/dL (0.6–1.2) |
| Blood urea nitrogen | 3.0 mmol/L (2.5–6.5) |
OTHER RELEVANT LAB RESULTS
Normal thrombophilia screen
Comments: A neurologic assessment and hematologic thrombophilia workup are essential parts of investigating a cryptogenic stroke or transient ischemic attack (TIA).
CHEST X-RAY
FINDINGS
Cardiothoracic ratio: 43%
Normal CXR.
Comments: There is no indication of enlarged right or left heart, and the pulmonary arteries are of normal size. Evidence of aortic coarctation is also not seen, which is pertinent given its association with berry aneurysms (see Case 24 ). The aortic knuckle is more prominent than would be expected in a 47-year-old female.
