Contributed by Nancy C. Karpinski, M.D. and Henry C. Powell, M.D.
-- Department of Pathology, U.S. Department of Veteran's Affairs Medical Center, La Jolla, CA and UCSD Medical Center, Division of Neuropathology, San Diego, CA
Published on line in September 1997
A 60-year-old male with a history of diabetes mellitus, tobacco use, and hypertension presented with a chief complaint of transient right-handed clumsiness and slurred speech. There was a three-day history of headache, nausea, vomiting, and falls. Medications on admission included insulin, lasix, and fosinopril. White blood cell count (WBC) was 12.5 x 109/L with a predominance of segmented neutrophils, but absent left shift. A chemistry panel and urinalysis were unremarkable. Initial neurological examination was non-focal and head CT was normal. Carotid ultrasound showed up to 70% stenosis of both the left and right internal carotid arteries. An admission diagnosis of transient ischemic attack was made and acetylsalicylic acid was given. There was a progressive decline in neurological function with dysarthria, ataxia, delirium, and lethargy. A diagnostic lumbar puncture was performed and appropriate pharmacotherapy was begun. A repeat head CT was abnormal demonstrating an anterior cerebral artery territory infarct. The patient died three weeks after admission of associated complications.