This document contains 6 case studies of patients presenting with symptoms of acute ischemic stroke. For each case, the patient history, examination findings, and questions about the lesion location, Oxford Community Stroke Project classification, and Trial of Org 10172 in Acute Stroke Treatment classification are provided. The cases include patients with symptoms of aphasia, hemiparesis, vertigo, personality changes, and gait imbalance. The document aims to teach classification of acute ischemic stroke patterns and localization through these clinical cases.

1. 7/10/2020
Dr.Tay JS
Hyperacute Ischemic Stroke
=Pattern and Localization=

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3. 1. Where is the lesion?
2. How to classify?

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12. Case Study

13. Case 1
• A 70-year-old woman was brought to the emergency room by an ambulance after she
developed difficulty communicating, and numbness and weakness of her right arm.
Her symptoms fluctuated in severity during a period of more than four hours.
• PMHx: HTN and DM
• Neurological examination:
• aphasia with impaired naming and reduced verbal fluency
• right homonymous hemianopia
• moderate right sensorimotor hemiparesis
Qz:
1. Where is the lesion?
2. OCSP classification?
3. TOAST classification?

14. Case 2
• A 64-year-old man presented with the acute onset of a speech disturbance, facial
palsy, and moderate weakness of the left arm and leg 75 minutes after symptom
onset. Except for a history of heavy smoking (45 pack–years), no vascular risk factors
were present. ECG and laboratory tests were normal.
• Neurology examinations:
• Alert
• Moderate dysarthria
• Left facial palsy (lower half)
• Left motor hemiparesis
Qz:
1. Where is the lesion?
2. OCSP classification?
3. TOAST classification?

15. Case 3
• A 77-year-old woman presented with vertigo, blurred vision, and hemisensory loss that
had started 8.5 hours before admission. She reported blood pressure levels above 200 mmHg
over the last 24 hours, and the initially suspected diagnosis was a hypertensive crisis.
Lowering of blood pressure in the emergency room, however, did not lead to symptom
amelioration. Within another 2.5 hours her symptoms progressed to a state of coma.
• Neurological examination
• On admission—> mild dysarthria and left hemisensory loss.
• A few hours late—> severe dysarthria, dysphagia, and progressive loss of consciousness,
together with rapidly evolving sensorimotor tetraparesis.
Qz:
1. Where is the lesion?
2. OCSP classification?
3. TOAST classification?

16. Case 4
• A 45-year-old woman of Turkish origin was brought to hospital by her relatives. They reported that they
noticed that the patient had a personality change during the past week. She appeared to be either “absent” and
showed a limited responsiveness to the surrounding world, or euphoric. Repeatedly, she would start to laugh or
cry without any reason.
• Furthermore, she had urinated on the sofa involuntarily. The symptoms began after a severe family
argument.
• Clinical examination: revealed that she was
• Slow to respond to queries or instructions
• Disorientated
• No visual, sensory, motor, or reflex abnormalities
Qz:
1. Where is the lesion?
2. OCSP classification?
3. TOAST classification?

17. Case 5
• A 35-year-old woman had a history of migraine with aura. She was in her 27th week of pregnancy when
she presented with acute aphasia for one hour without headache. Cerebrovascular risk factors included
hypercholesterolemia, former smoking, and a persistent foramen ovale.
• Neurological examination:
• Non-fluent with difficulties in verbal understanding and expression
• Slight right-sided brachiofacial hemiparesis.
• Deep tendon reflexes of arms and legs were symmetrically normal and Babinski’s signs were negative.
• Sensation of light touch, pain, and vibration was unimpaired.
• Coordination of the right upper limb was impaired within the range of the paresis
• Gait was normal.
Qz:
1. Where is the lesion?
2. OCSP classification?
3. TOAST classification?

18. Case 6
• A 47-year-old patient with no past neurological history reported gait imbalance and nausea
since getting up in the morning that day. His wife noticed a drooping eyelid on the left. Apart
from being a heavy smoker, there were no known risk factors or illnesses.
• Neurological examination:
• Left-sided limb ataxia,
• Right-sided thermal and pain analgesia
• Left ptosis and miosis
• Lingual and pharyngeal movements were normal.
• Muscle strength and discriminative sensibility were not affected
• No cervical or occipital pain was present.
Qz:
1. Where is the lesion?
2. OCSP classification?
3. TOAST classification?

19. =All the best!=