Correct!
5. All the above.
CT scans are poorly sensitive for cortical stroke in the first 24 hours. Lacunar strokes in the internal capsule typically cause hemiparesis but not aphasia (which is a cortical finding). Although we often consider spinal cord injuries as the cause of paraplegia or quadriplegia, a lateralized cord injury could cause a hemiparesis mimicking a stroke.
A CT angiogram of the neck was performed and demonstrated a focal 50% narrowing of the left common carotid artery (see below) compatible with, but not specific for an acute traumatic carotid dissection.
Figure 1. CT angiogram of the neck showing narrowing of the left common carotid artery (red arrow).
Carotid dissection is associated with trauma, often mild trauma, in about 40% of cases. It presents with headache or carotidynia in up to 90% of cases. A Horner’s sign with ptosis and miosis may be seen on the affected side. Transient ischemic attacks and strokes are seen in about 25% and 50% of patients respectively. Thrombolytic therapy should not be withheld if indicated for patients who suffer stroke (and can be treated within the first 3 hours of symptoms). Anticoagulation or antiplatelet therapy is indicated in all patients. Endovascular procedures and vascular surgery are usually not needed.
Aspirin was administered and vascular surgery consulted – although non-surgical management was planned. Shoulder pain persisted.
The next day, the patient complained of left upper extremity weakness. On examination 0/5 grip strength was noted bilaterally, with 4/5 shoulder abduction bilaterally.
What should be done next?