Ischemic stroke

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Ischemic stroke

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USMLE® Step 1 style questions USMLE

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A 59-year-old man is brought to the emergency department for evaluation of sudden onset of weakness of the right upper and right lower extremity for three hours. He does not have chest pain, shortness of breath, or leg pain. His past medical history includes recurrent infections when he lived in Mexico as a child, all of which were resolved with “home remedies.” He immigrated to the United States in his 30’s and was told by several PAs he has a cardiac murmur. He does not smoke cigarettes, drink alcohol, or use illicit drugs. His temperature is 37°C (98.6°F), pulse is 94/min and irregularly irregular, and blood pressure is 141/78 mmHg. The patient’s pulse oximetry is 99% on room air. He has marked weakness and sensory loss of  the right arm and right leg. There is no warmth, swelling or increased diameter of either leg. Further evaluation is most likely to reveal which of the following findings?  

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There are two main types of stroke: an ischemic stroke which is when there’s a blocked artery that reduces blood flow to the brain and a hemorrhagic stroke which is when an artery in the brain breaks, creating a pool of blood that damages the brain.

Of the two, ischemic strokes are much more common, and the amount of damage they cause is related to the parts of the brain that are affected and how long the brain suffers from reduced blood flow.

Now if symptoms self-resolve within 24 hours, it’s called a transient ischemic attack and there are usually minimal long-term problems.

OK - let’s start with some basic brain anatomy. The brain has a few regions - the most obvious is the cerebrum, which is divided into two cerebral hemispheres, each of which has a cortex - an outer region - divided into four lobes including the frontal lobe, parietal lobe, temporal lobe, and the occipital lobe.

There are also a number of additional structures - including the cerebellum, which is down below, as well as the brainstem which connects to the spinal cord.

The right cerebrum controls muscles on the left side of your body and vice versa.

The frontal lobe controls movement, and executive function, which is our ability to make decisions.

The parietal lobe processes sensory information, which lets us locate exactly where we are physically and guides movements in a three dimensional space.

The temporal lobe plays a role in hearing, smell, and memory, as well as visual recognition of faces and languages.

Finally there’s the occipital lobe which is primarily responsible for vision.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Stroke" The Lancet (2008)
  6. "Spontaneous intracerebral haemorrhage" BMJ (2009)
Elsevier

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