Acute stroke presenting as speech arrest

This 63 year old right-handed male was well until early on the morning of admission, when he had a 5 minute spell of tingling in the right cheek, followed by inability to speak. He remained alert and had intact memory of the events. He was able to communicate with hand gestures, but noted during transport to the hospital that his right hand was not functioning properly. He could not write with either the right or the left hand. His speech returned during transport to the hospital, less than 60 minutes after the episode's onset.

There was a history of Micronase-treated adult onset diabetes mellitus, and a 5 year history of arterial hypertension, treated with Vasotec.

He was alert and oriented, with paucity of speech, and some hesitation in word-finding. He had a mild right hemiparesis, affecting triceps and wrist extensors. Serum glucose was 166, but all other blood chemistry and hematology was normal. EKG showed evidence of left ventricular hypertrophy and a 24 hour Holter monitor was normal. Chest x-ray was normal except for a tortuous aorta. MRA was normal. Myocardial infarction was ruled out. He was started on intravenous heparin, then converted to warfarin. Over the next 7 days, the deficits slowly resolved.

Magnetic Resonance Angiography:

Tour:

Some details have been altered to protect confidentiality.
Keith A. Johnson (keith@bwh.harvard.edu), J. Alex Becker (jabecker@mit.edu)