From the Department of Medicine, Division of Cardiology (M.U., U.S., M. Shotwell, M. Shetty, D.K.K.) and Department of Radiology (W.F., J.J.), University of Louisville School of Medicine, Rudd Heart & Lung Center, 201 Abraham Flexner Way, Ste 600, Louisville, KY 40202.
Radiology. 2024 Jul;312(1):e232440. doi: 10.1148/radiol.232440.
A 43-year-old male patient with no known past medical history presented to the emergency department with new-onset bitemporal headache, dizziness, and bilateral lower extremity weakness for 1 day. The patient denied chest pain, shortness of breath, cough, or recent exposure to sick individuals. He was not on any medications and denied alcohol or illicit drug use. Vital signs were unremarkable. Physical examination was notable for a left-sided pronator drift and bilateral dysmetria that was more pronounced on the left. Results of routine laboratory workup, including complete blood count, metabolic panel, and high-sensitivity troponin level, were normal. An electrocardiogram revealed sinus tachycardia with a heart rate of 102 beats per minute, T-wave inversions in the inferior leads, left axis deviation, incomplete right bundle branch block, and frequent premature ventricular contractions. A radiograph of the chest was unremarkable. CT of the head without contrast enhancement demonstrated no acute intracranial abnormities. MRI of the brain without contrast enhancement revealed multiple acute infarcts involving left posterior inferior cerebellar artery distribution, right cerebellar hemisphere, right mesial temporal lobe, and right posterior limb of the internal capsule. CT angiography of the head and neck showed an occlusion of the right posterior cerebral artery near its origin, with a trace of distal flow. Given that these findings were concerning for a cardioembolic etiology of acute ischemic stroke, transesophageal echocardiography was performed. This showed mild left ventricular systolic dysfunction with an ejection fraction of 40%, mild global hypokinesis, and an additional finding also seen at subsequent cardiac CT and MRI that will be disclosed in part 2 of the case. The patient was started on systemic anticoagulation and guideline-directed medical therapy for heart failure with reduced ejection fraction. CT of the chest showed no evidence of lymphadenopathy or abnormalities in the lung parenchyma or interstitium. Coronary CT angiography was performed (Fig 1), followed by cardiac MRI (Fig 2).
一位 43 岁的男性患者，既往无病史，因突发双侧颞部头痛、头晕和双侧下肢无力 1 天就诊于急诊科。患者否认胸痛、呼吸急促、咳嗽或最近接触过患病个体。他没有服用任何药物，也否认饮酒或使用非法药物。生命体征无异常。体格检查发现左侧旋前漂移和双侧运动障碍，左侧更为明显。常规实验室检查结果包括全血细胞计数、代谢谱和高敏肌钙蛋白水平均正常。心电图显示窦性心动过速，心率为 102 次/分，下壁导联 T 波倒置，左轴偏，不完全右束支传导阻滞，频发室性期前收缩。胸部 X 线片无异常。头部 CT 平扫未见急性颅内异常。头部 MRI 平扫未见增强剂，显示多个急性梗死灶，累及左侧后下小脑动脉分布区、右侧小脑半球、右侧内侧颞叶和右侧内囊后肢。头颈部 CT 血管造影显示右侧大脑后动脉起源处闭塞，有少许远端血流。鉴于这些发现提示急性缺血性脑卒中的栓子来源可能为心源性，故进行了经食管超声心动图检查。结果显示轻度左心室收缩功能障碍，射血分数为 40%，轻度整体运动功能减退，在随后的心脏 CT 和 MRI 上也发现了另一个异常，将在病例的第 2 部分中部分披露。患者开始接受全身抗凝和针对射血分数降低型心力衰竭的指南导向的药物治疗。胸部 CT 未见淋巴结肿大或肺实质或间质异常。进行了冠状动脉 CT 血管造影（图 1），随后进行了心脏 MRI（图 2）。
