All in the Family

A CLINICAL PROBLEM-SOLVING article by Joshua Easter from Children's Hospital of Boston.
A 34-year-old woman presented to a community hospital with aphasia. Her husband reported that her condition had been normal until 2 hours earlier, when her arms and legs suddenly shook for several seconds. Immediately afterward, she was unable to speak or to move her limbs on the right side. There was no incontinence or tongue biting.
On physical examination, the patient was afebrile and had a regular pulse. Her gaze deviated to the left. She was mute and followed spoken commands intermittently. On neurologic examination, the patient was aphasic and had right homonymous hemianopia. She had a facial droop on the right side, complete paralysis of the right arm, and partial paralysis of the right leg. Strength was normal on the left side. Her reflexes were absent on the right side and normal on the left. Plantar responses were extensor on the right side and flexor on the left. Approximately 3½ hours after the onset of symptoms, a CT scan of the head revealed a hyperdense left middle cerebral artery.
The abrupt onset of a focal neurologic deficit is a true emergency. When an ischemic stroke occurs in a young patient without the traditional vascular risk factors, alternative causes must be considered. [Original Article]