Home / Clinical cases / Sudden aphasia and arm weakness
Sudden aphasia and arm weakness
A 68-year-old right-handed man with atrial fibrillation suddenly develops weakness of the right face and arm and can't find his words. His wife last saw him well an hour ago.
Step 1 of 4
Which arterial territory is most likely affected?
Correct answer: E
Contralateral face and arm weakness with aphasia (dominant hemisphere) is a left MCA stroke. ACA strokes affect the leg more than the arm; PCA strokes cause a homonymous hemianopia (see cerebral arteries (ACA, MCA, PCA)).
Show answer
E
Contralateral face and arm weakness with aphasia (dominant hemisphere) is a left MCA stroke. ACA strokes affect the leg more than the arm; PCA strokes cause a homonymous hemianopia (see cerebral arteries (ACA, MCA, PCA)).
Step 2 of 4
Which way are his eyes most likely to deviate?
Correct answer: B
In a hemispheric stroke the eyes deviate toward the lesion, away from the weak side.
Show answer
B
In a hemispheric stroke the eyes deviate toward the lesion, away from the weak side.
Step 3 of 4
Which test comes first?
Correct answer: B
A noncontrast CT comes first because hemorrhage must be excluded before thrombolysis. Check the glucose too.
Show answer
B
A noncontrast CT comes first because hemorrhage must be excluded before thrombolysis. Check the glucose too.
Step 4 of 4
The CT shows no hemorrhage. His blood pressure is 170/95 mm Hg and he has no contraindications.
What is the most appropriate treatment?
Correct answer: C
He is within 4.5 hours of last known well and his BP is below 185/110, so IV thrombolysis is indicated. If CT angiography shows a large vessel occlusion, mechanical thrombectomy is added.
Show answer
C
He is within 4.5 hours of last known well and his BP is below 185/110, so IV thrombolysis is indicated. If CT angiography shows a large vessel occlusion, mechanical thrombectomy is added.
Key points
- Face and arm > leg + aphasia → left (dominant) MCA.
- Eyes look toward the lesion in hemispheric stroke.
- Noncontrast CT first; IV thrombolysis within 4.5 h if BP < 185/110.
Study: Cerebral arteries (ACA, MCA, PCA), Circle of Willis, Internal capsule