Command:

This patient presents with complaints of visual difficulties.

Please examine the patient and address any issues or concerns raised.

https://youtu.be/NKzMSWwQO9E

https://youtu.be/6crPi3841IU

https://youtu.be/Zn0LDSv1-Q4

Follow-Up Questions/Answers

Can you summarise this case for me?

• This 62-year-old man presented with a 1-day history of desisting visual difficulties and the suggestion of left-side neurological symptoms. This was in the setting of vascular risk factors of hypertension, type 2 diabetes and
• Examination revealed a left-sided homonymous hemianopia and reduced sensation throughout the left side. The remainder of the neurological examination was unremarkable.
• In summary, I am concerned this patient may have had a right middle cerebral artery stroke.

How did you localise the position of the lesion?

• Macular sparing is usually seen in posterior cerebral artery lesions due to the supply from the middle cerebral artery this taken with the left-sided sensory changes makes me feel the lesion is more likely therefore to be within the right middle cerebral artery.

In addition to your neurological examination, you also examined the heart. Can you explain why?

• I felt the pulse looking for any evidence of atrial fibrillation and examined the heart looking for any evidence of valvular heart disease. I examined the carotid pillar looking for a carotid bruit that may signify carotid stenosis.

How would you manage this patient with a suspected stroke?

• I would want an urgent CT of the brain looking for any hemorrhage and after this I would like to admit the patient to an Acute Stroke Unit.
• If as current guidelines suggest the patient was within current time windows for further treatment, I may wish to consider the patient for thrombolysis providing there are no contraindications. I may wish to consider this patient for a thrombectomy if further imaging suggests friable brain tissue.