Description

A 66-year-old taxi-driver presented with a 1 day history of frontal headache, confusion, amnesic episodes and declining eye sight. On examination, despite his cheery disposition he had no recollection of events of the past decade, his vision was limited to light perception and he had an ataxic gait. His medical history included ischaemic heart disease, hypertension, hypercholesterolaemia and an ex-smoking habit. His ‘stroke protocol’ CT scan and subsequent MRI and MR angiography revealed that he had suffered bilateral posterior cerebral artery infarcts supplying the occipital lobes and that the right-sided infarct had also resulted in haemorrhagic transformation in the hippocampal region of the temporal lobe (figures 1 and 2). A 24-h tape also revealed runs of atrial fibrillation. Formal neuropsychological assessment confirmed his cortical visual loss and short term memory deficit. Occupational therapy and physiotherapy assessment revealed that his difficulty with coordination was multifactorial, for example: poor vision, poor lighting in some areas of the ward, an inability to remember the ward layout and where he had last put important possessions such as hearing aid and glasses. This case demonstrates the importance of recognising stroke symptoms that do not meet the clear cut F.A.S.T campaign criteria but that also require prompt recognition and management. This case study is also a good example of clinical anatomy in action: the occipital and temporal location of this gentleman’s lesions correlates with the expected ‘text book’ neurological symptoms of visual impairment and memory loss respectively. In conclusion, this patient did experience some improvement with both his vision and memory. With regard to secondary prevention, this gentleman was started on warfarin and had his vascular risk factors minimised. Adaptations at home were also made to help with activities of daily living. However, this patient was discharged with a significant functional impairment. Unfortunately, this is not an uncommon outcome poststroke despite the best efforts of stroke rehabilitation teams across the country.1

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Figure 1

MRI scan: infarction in the posteromedial temporal lobes and occipital lobes bilaterally. Also evidence of some haemorrhagic transformation in right temporal region.

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Figure 2

MR angiography scan: bilateral occlusion of the distal posterior cerebral arteries.