Oxford Case Histories in TIA and Stroke Oxford Case Histories Series Editors Sarah Pendlebury and Peter Rothwell Published: Neurological Case Histories (Sarah Pendlebury, Philip Anslow, and Peter Rothwell) Oxford Case Histories in Cardiology (Rajkumar Rajendram, Javed Ehtisham, and Colin Forfar) Oxford Case Histories in Gastroenterology and Hepatology (Alissa Walsh, Otto Buchel, Jane Collier, and Simon Travis) Oxford Case Histories in Respiratory Medicine (John Stradling, Andrew Stanton, Anabell Nickol, Helen Davies, and Najib Rahman) Oxford Case Histories in Rheumatology (Joel David, Anne Miller, Anushka Soni, and Lyn Williamson) Oxford Case Histories in TIA and Stroke (Sarah Pendlebury, Ursula Schulz, Aneil Malhotra, and Peter Rothwell) Forthcoming: Oxford Case Histories in Neurosurgery (Harutomo Hasegawa, Matthew Crocker, and Pawanjit Singh Minhas) Oxford Case Histories in Geriatrics ( Sanja Thompson, Nicola Lovett, Sarah Pendlebury, and John Grimley Evans) Oxford Case Histories in TIA and Stroke Sarah Pendlebury Consultant Physician, NIHR Biomedical Research Centre, Research Fellow, Stroke Prevention Research Unit Nuffi eld Department of Clinical Neurosciences John Radcliffe Hospital Oxford, UK Ursula Schulz NIHR Clinician Scientist and Honorary Consultant Neurologist Stroke Prevention Research Unit Nuffi eld Department of Clinical Neurosciences John Radcliffe Hospital University Department of Clinical Neurology Oxford, UK Aneil Malhotra Cardiology Specialist Registrar John Radcliffe Hospital Oxford Deanery Oxford, UK Peter M. Rothwell Director, Stroke Prevention Research Unit, Nuffi eld Department of Clinical Neurosciences John Radcliffe Hospital Professor of Clinical Neurology, University of Oxford, Oxford, UK 1 1 Great Clarendon Street, Oxford ox2 6dp Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press, 2012 The moral rights of the authors have been asserted Database right Oxford University Press (maker) First published 2012 All rights reserved. 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Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose the same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Library of Congress Control Number: 2011945386 Typeset in Minion by Cenveo, Bangalore, India Printed in Great Britain on acid-free paper by CPI Group (UK) Ltd, Croydon, CR0 4YY ISBN 978–0–19–953934–5 10 9 8 7 6 5 4 3 2 1 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. A note from the series editors Case histories have always had an important role in medical education, but most pub- lished material has been directed at undergraduates or residents. The Oxford Case Histories series aims to provide more complex case-based learning for clinicians in specialist training and consultants, with a view to aiding preparation for entry- and exit-level specialty examinations or revalidation. Each case book follows the same format with approximately 50 cases, each compris- ing a brief clinical history and investigations, followed by questions on differential diagnosis and management, and detailed answers with discussion. All cases are peer-reviewed by Oxford consultants in the relevant specialty. At the end of each book, cases are listed by mode of presentation, aetiology, and diagnosis. We are grateful to our colleagues in the various medical specialties for their enthusiasm and hard work in making the series possible. Sarah Pendlebury and Peter Rothwell From reviews of other books in the series: Neurological Case Histories ‘. . . contains 51 cases that cover the spectrum of acute neurology and the neurology of general medicine—this breadth makes the volume unique and provides a formidable challenge . . . it is a heavy-duty diagnostic series of cases, and readers have to work hard, to recognise the diagnosis and answer the questions that are posed for each case . . . I recommend this excellent volume highly. . .’ Lancet Neurology This short and well-written text is . . . designed to enhance the reader’s diagnostic ability and clinical understanding . . . A well-documented and practical book.’ European Journal of Neurology Oxford Case Histories in Gastroenterology and Hepatology ‘ . . . a fascinating insight in to clinical gastroenterology, an excellent and enjoyable read and an education for all levels of gastroenterologist from ST1 to consultant.’ Gut This page intentionally left blank Preface The profile of stroke medicine has grown enormously in recent years owing to develop- ments in neuroimaging and treatments which have been accompanied by a rise in stroke-related research and thus knowledge about the condition. Stroke medicine is now an accepted specialty in its own right, spanning acute medicine, neurology, geriatrics, and rehabilitation medicine. Our aim in writing this book was to collect together a series of cases of interest and educational value to stroke physicians and those in general internal and emergency medicine, geriatrics, and neurology that would illustrate the breadth and complexity of stroke. The cases cover common and uncommon causes of stroke, management dilemmas, and conditions that may mimic cerebrovascular events. The format follows that of the other books in this series: case reports with questions followed by answers including detailed discussion of the diagnosis, differential diag- noses where relevant, and treatment. This format was chosen because it is extremely difficult to illustrate the practical process of clinical management within the tradi- tional textbook format and the best way to learn is through analysis of individual cases. Also, we believe it is more interesting to consider real cases, and one’s own dif- ferential diagnosis and treatment, than to read a text which does not require any effort on the part of the reader. A quick note for non-UK readers: in the United Kingdom, patients with TIA or minor stroke are often managed as outpatients. They are assessed in dedicated ‘TIA clinics’. These clinics are perhaps somewhat inaccurately called TIA clinics, even though both patients with TIA and with mild stroke are seen. We have also used this terminology in our book, as it reflects our clinical practice. We would like to thank the following general physicians, stroke physicians, neurolo- gists, and cardiologists for contributing cases, images, and/or for helpful comments on the manuscript: Dr William Bradlow, Dr Florim Cuculi, Dr Dennis Briley, Dr Matthew Giles, Dr Maggie Hammersley, Dr Hywel Jones, Dr Nicola Jones, Dr George Pope, Dr Sarah Smith, Dr Sanja Thompson, and Dr Andy Walden. Particular thanks go to Dr Wilhelm Küker for help with the neuroradiology and to Mrs Jean Brooks for secre- tarial assistance. Sarah Pendlebury Ursula Schulz Aneil Malhotra Peter Rothwell Oxford 2011 This page intentionally left blank Contents Abbreviations xi Table of normal ranges xiii Cases 1–51 1 List of cases by diagnosis 308 List of cases by clinical features 310 Index 311