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|Prompt=A 65-year-old right-handed man with history of poorly controlled hypertension and dyslipidemia is brought by his wife to the emergency department for sudden onset of right upper extremity paralysis and loss of sensation.  Brain MRI is shown below. Which of the additional findings is most likely to be present in this patient?
|Prompt=A 65-year-old right-handed man with history of poorly controlled hypertension and dyslipidemia is brought by his wife to the emergency department for sudden onset of right upper extremity paralysis and loss of sensation.  Brain MRI is shown below. Which of the additional findings is most likely to be present in this patient?


[[Image:Left MCA stroke.jpeg|center|400px]]
[[Image:WBR0612.jpeg|center|400px]]
|Explanation=The patient is presenting with right upper extremity hemiplegia and hemiparesis suggestive of a [[stroke]] in the [[middle cerebral artery]] (MCA).  The MRI of the brain confirms a stroke in the MRA territory. A stroke in the dominant right lobe might lead to contralateral right sided [[hemiplegia]] and [[hemiparesis]] in the upper extremity and right side of the face as well as [[aphasia]]; hence, the patient is expected to have a speech difficulty. A stroke in the [[MCA]] territory of the non dominant right lobe might lead to hemineglect.   
|Explanation=The patient in this scenario is presenting with right upper extremity hemiplegia and hemiparesis suggestive of a [[stroke]] in the [[middle cerebral artery]] (MCA).  The MRI of the brain confirms a stroke in the MCA territory. A stroke in the dominant right lobe classically leads to contralateral right sided [[hemiplegia]] and [[hemiparesis]] in the upper extremity and right side of the face as well as [[aphasia]]. Patients may present with any combination of these symptoms. A stroke in the [[MCA]] territory of the non dominant right lobe might lead to hemineglect.   


Shown below is an image depicting the vascular territories in the brain.
[[Image:Stroke_territories.jpg|center|600px]]
[[Image:Vascular-territories.gif|center|600px]]
 
 
Image in stem courtesy of radiopaedia http://radiopaedia.org/cases/left-mca-infarction.
|AnswerA=Paralysis of the right lower extremity
|AnswerA=Paralysis of the right lower extremity
|AnswerAExp=A [[stroke]] in the left MCA does not lead to paralysis of the right lower extremity, in fact, a stroke in the left [[anterior cerebral artery]] (ACA) may lead to paralysis of the right lower extremity.
|AnswerAExp=A [[stroke]] in the left MCA does not lead to paralysis of the right lower extremity, in fact, a stroke in the left [[anterior cerebral artery]] (ACA) may lead to paralysis of the right lower extremity.
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|AnswerD=Abnormal gait
|AnswerD=Abnormal gait
|AnswerDExp=Strokes in the posterior circulation and not in the MCA may lead to abnormal gait.
|AnswerDExp=Strokes in the posterior circulation and not in the MCA may lead to abnormal gait.
|AnswerE=Speech difficulty
|AnswerE=Speech impairment
|AnswerEExp=A stroke in the MCA in the dominant left side of the brain may lead to [[aphasia]].
|AnswerEExp=A stroke in the MCA in the dominant left side of the brain may lead to [[aphasia]].
|EducationalObjectives=A [[stroke]] in the dominant right lobe might lead to contralateral right sided [[hemiplegia]] and hemiparesis in the upper extremity and right side of the face as well as [[aphasia]].
|EducationalObjectives=A [[stroke]] in the dominant right lobe might lead to contralateral right sided [[hemiplegia]] and hemiparesis in the upper extremity and right side of the face as well as [[aphasia]].
|References=First Aid 2014 page 458
|References=Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute stroke. West J Emerg Med. 2011;12(1):67-76. '''(Image)'''<br>
First Aid 2014 page 458
|RightAnswer=E
|RightAnswer=E
|WBRKeyword=Stroke, Aphasia, MCA
|WBRKeyword=Stroke, Aphasia, MCA, Middle cerebral artery, Ischemic stroke, Speech impairment
|Approved=No
|Approved=Yes
}}
}}

Revision as of 22:10, 7 October 2014
Author [[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Anatomy, MainCategory::Pathophysiology
Sub Category SubCategory::Neurology
Prompt [[Prompt::A 65-year-old right-handed man with history of poorly controlled hypertension and dyslipidemia is brought by his wife to the emergency department for sudden onset of right upper extremity paralysis and loss of sensation. Brain MRI is shown below. Which of the additional findings is most likely to be present in this patient?
File:WBR0612.jpeg
]]
Answer A AnswerA::Paralysis of the right lower extremity
Answer A Explanation [[AnswerAExp::A stroke in the left MCA does not lead to paralysis of the right lower extremity, in fact, a stroke in the left anterior cerebral artery (ACA) may lead to paralysis of the right lower extremity.]]
Answer B AnswerB::Loss of sensation on the left side of the face
Answer B Explanation AnswerBExp::A stroke in the left MCA may lead to loss of sensation on the contralateral right side of the face and not the left side of the face.
Answer C AnswerC::Hemineglect
Answer C Explanation [[AnswerCExp::A stroke in the MCA in the non dominant right side of the brain may lead to hemineglect while a stroke in the MCA in the dominant left side of the brain may lead to aphasia.]]
Answer D AnswerD::Abnormal gait
Answer D Explanation AnswerDExp::Strokes in the posterior circulation and not in the MCA may lead to abnormal gait.
Answer E AnswerE::Speech impairment
Answer E Explanation [[AnswerEExp::A stroke in the MCA in the dominant left side of the brain may lead to aphasia.]]
Right Answer RightAnswer::E
Explanation [[Explanation::The patient in this scenario is presenting with right upper extremity hemiplegia and hemiparesis suggestive of a stroke in the middle cerebral artery (MCA). The MRI of the brain confirms a stroke in the MCA territory. A stroke in the dominant right lobe classically leads to contralateral right sided hemiplegia and hemiparesis in the upper extremity and right side of the face as well as aphasia. Patients may present with any combination of these symptoms. A stroke in the MCA territory of the non dominant right lobe might lead to hemineglect.

Educational Objective: A stroke in the dominant right lobe might lead to contralateral right sided hemiplegia and hemiparesis in the upper extremity and right side of the face as well as aphasia.
References: Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute stroke. West J Emerg Med. 2011;12(1):67-76. (Image)
First Aid 2014 page 458]]

Approved Approved::Yes
Keyword WBRKeyword::Stroke, WBRKeyword::Aphasia, WBRKeyword::MCA, WBRKeyword::Middle cerebral artery, WBRKeyword::Ischemic stroke, WBRKeyword::Speech impairment
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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