Violent Cough, Slurred Speech, and Ptosis in a Middle-Aged Man

Francesco Brigo, MD; Giampaolo Tomelleri, MD


August 23, 2022

Physical Examination and Workup

Upon physical examination, his oral temperature is 97.3°F (36.3°C). His pulse is regular with a rate of 94 beats/min. His blood pressure is 195/105 mm Hg. Head and neck findings are normal. His lungs are clear to auscultation and have normal respiratory effort. No cardiac murmurs are detected. His abdomen is soft and nontender, with normal bowel sounds on auscultation.

Upon neurologic examination, the patient is alert and oriented to time and place. His speech is slurred and dysarthric. Upon cranial nerve examination, the right pupil constricts from 2 mm to 1.5 mm in response to light, whereas the left pupil constricts from 3 mm to 2 mm. The right eyelid has 3 mm of ptosis compared with the left eye, and the right eye appears to be smaller than the left. Pupillary asymmetry is more apparent when lights in the room are dimmed. Funduscopic examination reveals normal fundi. Visual acuity is normal bilaterally. The extraocular movements are intact.

Facial sensation is decreased to light touch and pinprick on the left side. The patient has a decreased left nasolabial fold. He has weak movements of the left side of the face, without forehead involvement. The gag reflex is present, and normal palate elevation is observed. After pinching the left side of the neck, the left pupil dilates normally (ciliospinal reflex). After pinching the right side of the neck, the right pupil does not dilate. He is unable to stand and walk. Muscular tone is flaccid on the left side but normal on the right. He has marked left hemiparesis.

The patient's reflexes are normal throughout, except for an upgoing plantar response on the left side, compared with a downgoing one on the right. The patient reports decreased sensation to light touch, temperature, pinprick, joint position, and vibration on the left half of the body. His National Institute of Health Stroke Scale (NIHSS) score is 11.

Routine laboratory analyses are performed, and results are normal. Chest x-ray findings are normal. ECG shows left ventricular hypertrophy. A noncontrast CT scan of the head reveals a hyperdense right middle cerebral artery (Figure 1).

Figure 1.

Conventional angiography reveals stenosis at the origin of the right internal carotid artery, with an abrupt narrowing of its lumen ("rattail-filling defect"; Figure 2).

Figure 2.


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