Case 392

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.

According to the clinical history and the radiological exams presented, what is the probable etiology for the neurological condition?

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.

What is the probable diagnosis and the more appropriate management?

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