Is rt-PA indicated?

Suppose you meet with this patient, what will you do?

This 43-year-old lady has hypertension and DM about 5-6 years without medical treatment. This time, she came to our ER because she felt dizzy and facial flushing. Initially at ER, high blood pressure( 270/134mmHg) was found. Besides, hypokalemia(K= 3.3 meq/L) and hyperglycermia(325mg/dl) were also noted. There was no headache, blurred vision, or neurological focal sign. She was treated as hypertensive crisis. After NTG injection, she was transferred to ICU at 17:55. Unfortunately, left limbs weakness and slurred speech occurred about 18:20 PM. At that time, blood pressure was lowered to 95/60 mmHg. NTG was stopped immediately. Left hemiparesis, hypothesia, dysarthria, dysphagia, left central type facial and dizziness persisted. Neurologist was called to see this lady at 19:00. Head CT was normal and NIHSS score was 7. Her brother hesitated thrombolytic therapy for fear of the risk of intracranial bleeding. Emergent brain MRI was therefore done at 20:00, and it revealed acute infarction on right pons and no stenosis of basilar artery. According to her clinical presentation and neuroimaging findings, will you prescribe rt-PA to treat her stroke?

百日癲癇

5月4日下午4點左右，我接受一位自醫學中心轉來的病人。他因為持續抽搐，已經在那家醫院的加護病房住院百日。我和他的家人一樣，為他不幸的遭遇感到難過。我看過這位病患之後，心裡浮現一個念頭：一個抽筋100天的腦子，會變成甚麼情況？

Clock Drawing

這位病人於其左額葉有個5公分大的meningioma。我請他畫個三點半的時鐘，病人先是在中央畫個小圈，然後轉著紙寫數字。從1寫到12之後又猶豫許久，經提示，才將時針畫在3-4之間。而分針，他就畫不下去了。

Cortical function

「眾裏尋他千百度，
驀然回首，
那人卻在燈火闌珊處。」
您要不要試試，
以Neurology的觀點，
分析一下這詞所涉及的cortical function?

買了8條菸

有位菸槍發生中風，病變部位在left angular gyrus附近，症狀有acalculia, 但沒有Gerstmann syndrome的其它症狀。病患中風後，曾經一次買了八條香菸，而買了之後馬上後悔。這是怎麼回事？

Childish after pontine infarct

有位50歲的先生，發生了right pontine paramedian infarct。家屬注意到，自從中風之後，病人的表現似乎比較幼稚。您注意過這種情況嗎？

A 50-year-old gentleman suffered from a right paramedian pontine infarct. Family reported that this patient appeared a little bit childish after stroke. Did you have similar experience before?

Dysarthria clumsy hand syndrome in a patient with ankylosing spondylitis

On Feb 4, 2009, a 50-year-old man who already had ankylosing spondylitis, diabetes mellitus, hypertension, hyperlipidemia, obstructive sleep apnea syndrome and gout came to my OPD because he had suffered from dysarthria and clumsy right hand for 2 weeks. He appeared central obesity, and laboratory revealed leukocytosis (WBC count=16,000 /uL). Brain MRI disclosed a paramedian pontine infarct. There was no stenosis in major intracranial arteries (shown by MRA).

Question 1: which side of pons was infarcted to cause his symptom?
Question 2: what is the relationship between his stroke and those above-mentioned medical problems? Do you believe ankylosing spondylitis is the culprit of his pontine infarct?