Cerebral Hemispheres and Vascular supply

A 68-year-old man suddenly developed “the worst headache of my life.” Mild nuchal rigidity.

Subarachnoid hemorrhage

A 67-year-old woman suddenly developed left leg weakness and difficulty using her left hand.

Infarct of right medial frontal lobe including foot motor cortex, right anterior cerebral artery

A 63-year-old woman went to an ophthalmologist because of episodes of decreased vision in her “right eye” and headaches.

History

Past medical history was notable for diabetes, elevated cholesterol, and coronary artery disease. About 5 or 6 weeks ago the patient began having episodes of sudden “blurry wavy” vision. She believed this was mostly in the right eye. Homonymous homopenia

Left PCA infarct

A 71-year-old right-handed man with a long history of cigarette smoking and hypertension had an episode 5 months before admission of right hand weakness and speech difficulty, “mixing up words.” Since then, he has had several episodes, lasting a few minutes each, of dim, blurry vision in the left eye. Finally, he fell on three separate occasions when his right leg suddenly gave out, most recently on the day of admission. Examination was normal except for a high-pitched bruit audible over the left carotid artery

right medial primary motor cortex, left superior MCA, left opthalmic artery

A 45-year-old man was brought to the emergency room because of right face and arm weakness and inability to speak.

left MCA superior division

A 64-year-old, right-handed man with a history of schizophrenia suddenly began talking nonsense and repeating himself over and over again.

Left MCA inferior division

An 84-year-old woman with a history of hypertension and diabetes had two episodes of slurred speech and right-sided weakness on two consecutive days, and on the third day she developed persistent dysarthria and right hemiplegia. Exam was normal except for right facial weakness sparing the forehead, dysarthria, decreased right-sided tone, 0/5 power in the right arm and leg, and right upgoing plantar response

Internal capsule infacts, occlusion of lenticulostriate arteries. MCA

The patient was working in his yard removing weeds on the day of admission when his wife noted an episode of slurred speech around 2:00 p.m., which then improved. He was fine until 4:45 p.m., when he suddenly developed right-sided weakness, slumped to the right, could not speak, and had a leftward gaze deviation. His wife called an ambulance. Past medical history was notable for hypertension

Left MCA stem infarct

A 91-year-old, right-handed woman with a history of paroxysmal atrial fibrillation called her daughter one morning because she was unable to get her arm through the left sleeve of her dress. The patient’s speech sounded slightly slurred over the telephone, so her daughter called an ambulance. Examination was notable for left facial weakness sparing the forehead, mild dysarthria, left arm pronator drift, 4/5 strength in the left arm, and brisk 3+ reflexes in the left arm compared to 2+ reflexes in the right arm. In addition, there was occasional extinction on the left side to double simultaneous visual or tactile stimulation. The remainder of the exam was essentially normal, including intact visual fields and normal leg strength.

MCA superior infarct, right primary motor cortex face and arm.

A 61-year-old, left-handed security guard had an episode of left hand tingling lasting less than an hour that was reported to medical staff by a friend. The next day he was at the grocery store buying a lottery ticket and reportedly slumped briefly to the floor. He denied that anything was wrong but said, “They called an ambulance because they said I had a stroke.” On examination he was unaware of having any deficits and wanted to go home. He had profound left visual neglect, describing only the curtains to the far right in a picture of a complex visual scene and reading only the right two words on each line of a magazine article. When trying to write, he moved the pen in the air off to the right of the page. He had no blink to threat on the left, a marked right gaze preference, and mildly decreased left nasolabial fold. Spontaneous movements were decreased on the left side, but with provocation he was able to achieve 4/5 strength in the left arm and leg. He was able to feel touch on the left side but had extinction on the left to double simultaneous tactile stimulation. Reflexes were slightly brisker on the left

right tempoparietal region, Right MCA inferior division

A 63-year-old man with a history of atrial fibrillation, hypertension, cigarette smoking, and bipolar disorder was digging a hole in his yard with a friend when at 9:30 p.m. his left leg gave out and he fell to the ground. He friend noticed he could not move his left side and immediately called an ambulance. At 10:15 p.m. in the local emergency room a telestroke consult was initiated and he was examined by a neurologist from a larger hospital via video. On exam he was alert and fully oriented but denied any weakness or other abnormalities. He had a left visual field deficit, dysarthric speech, left face weakness sparing the forehead, 0/5 strength in the left arm, and 0/5 strength in the left leg. Reflexes and sensation were not tested.

Right MCA infarct, large right cerebral cortex infarct

A 52-year-old right-handed woman went to her physician the morning after developing difficulty raising her left arm.

watershed infarct ACA-MCA, right motor cortex

Two weeks prior to admission, the patient noticed difficulty eating. She was admitted to the hospital on the general surgery service when a large mass was found in her abdomen, and an endoscopic biopsy revealed gastric carcinoma. On the evening after admission, the nurse found her lying on her left arm in an awkward position. The patient complained of a right frontal headache and left arm numbness. The surgical intern found that she had left-sided weakness, and a neurology consult was called.

Right face and arm motor cortex, right MCA