A 60-Year-Old Man Is Brought To The ER By Ambulance Because

A 60 Year Old Man Is Brought To The ER By Ambulance Because Of Slurred

A 60-year-old man is brought to the ER by ambulance because of slurred speech and left side weakness. His wife states they went to bed at 11 pm and woke up at 5 am with his symptoms. He has a history of coronary artery disease, hypertension, hypercholesterolemia, and a previous heart attack at age 50. Currently, he is unable to move his left arm and leg. He experienced an episode of amaurosis fugax (temporary vision loss) in his right eye one month prior that lasted approximately five minutes.

About three months ago, his wife reports bilateral leg pain lasting around 15 minutes during a walk. He is taking a daily aspirin, an ACE inhibitor, and a statin. His past medical history includes alcohol consumption and past smoking but he quit after his heart attack. On examination, his blood pressure is markedly elevated at 195/118 mm Hg, with a pulse of 106 beats per minute, respiratory rate of 18 breaths per minute, temperature of 99.8°F, and oxygen saturation of 97% on room air.

He presents with pupils that are equal and reactive to light, with intact ocular movements; however, he is unable to voluntarily turn his eyes to the left. His neck is supple, with no jugular venous distension or carotid bruits. Lung and heart examinations are normal, with no murmurs, and the abdomen is unremarkable. His extremities are poorly perfused distally. Neurological assessment shows he is alert and oriented but unaware of his condition. He exhibits impaired awareness and attention towards stimuli on his left side, with mild dysarthria but fluent speech and intact comprehension.

On neurological examination, there is mild weakness on the left side of the face, left homonymous hemianopsia, and inability to move his left arm and leg. He displays hyperreflexia and a positive Babinski sign on the left side (upgoing left great toe). Nystagmus, ptosis, tongue deviation, and uvula deviation are absent.

Questions for the patient:

1. Have you experienced any recent episodes of weakness, numbness, or visual changes before this current event?

2. Do you have any accompanying symptoms such as dizziness, difficulty swallowing, or severe headache?

Subjective data:

- Onset of symptoms occurred between 11 pm and 5 am

- Reported left-sided weakness and slurred speech

- Past episodes of amaurosis fugax in the right eye one month ago

- Recent bilateral leg pain during walking

- Medical history of coronary artery disease, hypertension, hypercholesterolemia, previous myocardial infarction

- Medications: aspirin, ACE inhibitor, statin

- Past alcohol and cigarette use

- Wife's observations and reports of symptoms and prior episodes

Objective data:

- Vital signs: BP 195/118 mm Hg, pulse 106, RR 18, Temp 99.8°F, O2 sat 97%

- Pupils equal and reactive, intact ocular movements

- Inability to turn eyes voluntarily to the left

- No jugular distension or carotid bruits

- Clear lungs, normal heart sounds

- No abdominal abnormalities

- Poor distal perfusion in limbs

- Neurological findings: alert and oriented, lack of awareness, impaired attention on the left, mild dysarthria, fluent speech, comprehension intact

- Left facial weakness, left homonymous hemianopsia

- Hemiparesis on the left (arms and legs), hyperreflexia, Babinski sign positive on the left

- No nystagmus, ptosis, or cranial nerve deviations evident

Likely diagnosis:

The clinical presentation strongly suggests an ischemic stroke, specifically a right-sided cerebrovascular event affecting regions responsible for motor control and visual pathways. The patient's sudden left-sided weakness, hemianopsia, and neglect point toward a right hemispheric ischemic stroke involving the middle cerebral artery (MCA) territory. The absence of cerebellar signs such as nystagmus and the presence of hyperreflexia and Babinski sign also support an upper motor neuron lesion consistent with a stroke.

According to the American Heart Association/American Stroke Association guidelines, such signs and symptoms in the setting of hyperacute presentation point toward an ischemic stroke (Powers et al., 2018). The prior history of amaurosis fugax increases the suspicion of carotid or intracranial large-vessel atherosclerotic disease. Hypertension, hypercholesterolemia, and previous coronary artery disease are significant risk factors that heighten the likelihood of cerebrovascular events due to atherosclerosis (Benjamin et al., 2011).

Further investigations should include neuroimaging—preferably non-contrast CT scan of the head to rule out hemorrhagic stroke, followed by MRI for precise ischemic delineation. Carotid Doppler ultrasound and cardiac evaluation via echocardiogram are indicated to identify potential embolic sources (Katan & Luft, 2018).

Review of course material, literature, and websites:

Strokes are classified primarily into ischemic (85%) and hemorrhagic (15%) types, with ischemic strokes resulting from occlusion of cerebral arteries by thrombi or emboli (Benjamin et al., 2011). The patient's presentation with sudden neurological deficits, neglect, and homonymous hemianopsia are classic for middle cerebral artery infarcts. Elevated blood pressure is common during acute stroke episodes; however, it may need management to prevent further hemorrhagic transformation (Powers et al., 2018).

The role of atherosclerosis in stroke etiology is well established, especially in patients with risk factors like hypertension, hyperlipidemia, and coronary artery disease (Katan & Luft, 2018). The prior episodes of amaurosis fugax and bilateral leg pain reinforce the suspicion of systemic atherosclerosis affecting multiple vascular beds. The episode of amaurosis fugax was likely a transient ischemic attack (TIA) signaling carotid or intracranial artery stenosis.

Treatment focuses on reperfusion strategies like thrombolysis within the appropriate time window (up to 4.5 hours from symptom onset), secondary prevention with antiplatelet agents, statins, antihypertensives, and lifestyle modifications (Powers et al., 2018). EXIT criteria and stroke severity scales (such as NIH Stroke Scale) guide management decisions.

References

Benjamin, E. J., Muntner, P., Alonso, A., et al. (2011). Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation, 139(10), e56-e528. https://doi.org/10.1161/CIR.0000000000000659

Katan, M., & Luft, A. (2018). Global burden of stroke. Seminars in Neurology, 38(2), 208–211. https://doi.org/10.1055/s-0038-1641241

Powers, W. J., Rabinstein, A. A., Ackerson, T., et al. (2018). Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 49(3), e46-e110. https://doi.org/10.1161/STR.0000000000000158