No other significant stenosis or large vessel occlusion were identified. Head and neck CT angiography demonstrated a hypoplastic left vertebral artery with occlusion at the C2-C3 level to the level of the origin of the left posterior inferior cerebellar artery (PICA) (Figure 3). Head CT without contrast showed global cerebral atrophy but no hemorrhage or other acute findings were observed. His chest radiograph showed enlarged cardiac silhouette and prominent ascending aorta but no other abnormality (Figure 2). Mr O’s ECG showed normal sinus rhythm with first-degree atrioventricular (AV) block, left axis deviation, and left ventricular hypertrophy with QRS widening (Figure 1). The only notable laboratory findings were mildly elevated hemoglobin A1c at 6.6%, hypertriglyceridemia at 191 mg/dL, and elevated low-density lipoprotein (LDL) level at 116 mg/dL. Diagnostic Testing and Imaging StudiesĬomplete blood count and blood and urine chemistry were ordered, and results showed no significant abnormalities in electrolytes, renal function, cardiac enzymes, coagulation panel, or cell counts. Mr O had a National Institute of Health Stroke Scale (NIHSS) score of 6 (3 for left-sided complete hemifacial paralysis, 1 for decreased sensation, 1 for left-sided dysmetria, and 1 for dysarthria). Other notable findings include left side dysmetria and dysdiadochokinesia, horizontal nystagmus, and truncal ataxia. He had left lower facial weakness and decreased sensation to pinprick on the right side of his face in the V1-V3 distribution. On physical examination, Mr O had repeated throat clearing, fluent speech with mild dysarthria, left-sided Horner syndrome with left eyelid ptosis, and left eye miosis. He was afebrile with a normal heart rate, respiration, oxygen saturation, and fingerstick blood glucose level. His initial vital signs were notable for blood pressure of 162/85 mm Hg, but were otherwise unremarkable. He was not taking any anticoagulating medications. The stroke team was alerted upon Mr O’s arrival, in consideration of his presentation and lack of prior history. Mr O noted that when he ran his hands under the sink he noticed his right hand couldn’t feel the hot water. When he awoke 3 hours later, he felt “off balanced” and walked to the bathroom with difficulty. He reports that symptoms began 8 hours earlier, at which time he went to sleep. Mr O, age 57 with no significant past medical history, was brought to the emergency department (ED) by emergency medical services (EMS) with left-sided headache and dizziness.
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