Medical history A 84-year-old man with a history of smoking (75 pack-years) and alcoholism, no other comorbidity related, presented with dysarthria, right hemiataxia and hemiparesis, mainly in the right arm, after fall on waking. Physical examination showed verbal response, isochoric and photoreactive pupils, Babinski positive on the right, sinus rhythm on ECG. Brain magnetic resonance and magnetic resonance angiography were requested. Magnetic resonance (MR) image of the brain, axial section, T2-weighted fluid-attenuated inversion recovery image.Magnetic resonance (MR) image of the brain, axial section, diffusion-weighted image (DWI).Magnetic resonance angiography of the neck.Cerebral Magnetic resonance angiography. Question:According to the clinical history and the radiological exams presented, what is the probable etiology for the neurological condition? Cardioembolic stroke caused by atrial fibrillation, which occludes the flow of the right posterior cerebral artery. Artery-to-artery embolic stroke, which occludes the flow of the left posterior cerebral artery. Lacunar infarction, occlusion of a thalamic small penetrating artery, branch of the left posterior cerebral artery. Artery-to-artery embolic stroke originated from left carotid atherosclerosis, occluding the left posterior cerebral artery. Test question (UNIFESP 2015 - Intensive Care Medicine) A 49-years-old patient presented to the emergency room with his brother, who reported that he had a sudden loss of strength in the left arm, he also presented a difficulty of communication. Both symptoms started 35 minutes ago during physical activity at the gym. Past medical history: systemic arterial hypertension and smoking. On examination: alert, obeying commands, total right hemiparesis with brachio-facial predominance (muscle strength grade II). Afasia, no stiff neck, isochoric and photoreactive pupils. Blood pressure: 190/110 mmHg. Heart rate: 88bpm; RF: 14. Computed tomography of the brain and laboratory tests were normal.Question:What is the probable diagnosis and the more appropriate management? Subarachnoid hemorrhage. The evolution should be carefully observed, with magnetic resonance imaging performed as soon as possible. Transient ischemic stroke. In view of the time lapse, it is not a candidate for reperfusion thrombolytic therapy. It is not recommended to control the hypertension in this acute phase. Ischemic stroke. In view of the time lapse, he is not a candidate for reperfusion thrombolytic therapy. Aspirin and neurological surveillance are recommended. Ischemic stroke. In view of the time lapse, this is a candidate for reperfusion thrombolytic therapy with r-tPA. However, it is necessary an adequate pressure control and to make sure of the absence of other contraindications. Hemorrhagic stroke. It is recommended an adequate pressure control and repeat the tomography in the first 24 hours. Time is Up! Time's up
