Triage: BIBA FROM HOME, L FACIAL DROOP. LSN APPROX 3 AM. HX HTN, NON COMPLIANT WITH MEDS. L EYE RED AND IRRITATED.

History of Present Illness: Elderly female brought in as a possible stroke code with last known well at home time of 4 AM with left-sided facial droop slurred speech and blood pressure 250/92. Patient states she has actually had gradually worsening facial weakness since yesterday evening and at 7 PM had trouble drinking because she was drooling out of the left side. She states she stopped taking her blood pressure medicine about a month ago because she did not think she needed it. She has had headaches for the last month but they are not different from headaches she has had other times in the past. nNo sudden onset, fever or chills. No other complaints. Specifically no arm or leg weakness or change in vision or speech

Vital Signs: T: 36.7 °C, HR: 62,  RR: 15,  BP: 168/91,  SpO2: 95%

Physical Exam:

  • ENT: normal
  • EYE: No fluoresceine uptake
  • CNS: Normal speech. Moderate to severe weakness to left face. Unable to close her left eye. Otherwise no focal weakness. Alert and oriented. No pronator drift

Initial Diagnostic Testing:

  • CBC: normal
  • Chem-7: Normal except for glucose of 250
  • Imaging: see below

   

What does the CT show?

  • A) Aneurysm
  • B) Bleed
  • C) CVA
  • D) None of the above

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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QUIZ ANSWER:

  • A) Aneurysm – CORRECT
  • B) Bleed – UNLCLEAR
  • C) CVA
  • D) None of the above

 

CASE CONCLUSION:

  • CT scan read as showing a 1 cm pontine bleed with an adjacent basilar artery aneurysm.
  • CTA was equivocal for a bleed or just an aneurysm.  Case discussed with neurosurgery who recommended telemetry bed and to keep blood pressure under 160 systolic.
  • Next day MRI ruled out a bleed and the pseudo-Bell’s palsy was thought to be due to pontine compression from the aneurysm.  IR and neurosurgery recommended against intervention.
  • Steroids and acyclovir continued just in case there was also facial nerve swelling/compression w/in the temporal bone

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