RESIDENT & FELLOW SECTION Section Editor John J. Millichap, MD Joy Vijayan, MD Teoh Hock Luen, MRCP Eric Ting, FRANZCR Chou Ning, FRCS Correspondence to Dr. Vijayan: drjoyvijayan@gmail.com Pearls & Oy-sters: Localization in acute stroke management Thinking straight when it comes down to crunch time PEARLS Localization of the stroke syndrome with possible elucidation of the underlying pathophysiol- ogy is of paramount importance before initiating IV recombinant tissue plasminogen activator (rtPA). OY-STERS A high NIH Stroke Scale score in isola- tion, without due consideration of the underlying stroke mechanism, should not be used as a selection criteria for acute stroke therapy with IV rtPA. Dedicated and localized imaging studies should be performed if the clinical picture is not typical of a stroke syndrome, especially so if IV rtPA is being considered. CASE HISTORY A 56-year-old woman presented to the emergency department of our hospital with acute-onset weakness of the right upper and lower extremities of 2.5 hours’ duration. This was associated with mild pain and vague sensory symptoms involving the homolateral side. The NIH Stroke Scale score at presentation was 9. The initial CT scan showed no evidence of an intracranial bleed. CT angiogram showed normally opacified extracranial carotids, extracranial vertebrals, and intracranial vasculature. On examination, the heart rate was 72 beats/min and regular, and the blood pressure was 148/80 mm Hg. The Acute Stroke Team of our hospital was activated for IV thrombolysis. On further neurologic assessment, the patient had no features of an expressive or receptive aphasia. There were no signs of any inattention or neglect. The extraocular movements were complete with normally reacting pupils. There was no impairment of sensation over the face or any evidence of facial nerve palsy. Palatal movements were complete and symmetrical with no deviation of the tongue. Mus- cle tone on the right was decreased with grade 0/5 power of the right upper extremity and 1–2 power of the right lower extremity. Deep tendon reflexes on the right were absent with an upgoing plantar on the right. Muscle power and reflexes were normal on the left. Sensory system examination revealed mildly reduced proprioception and vibration sense on the right. Pain and temperature sense was grossly normal on both sides. In view of the absence of any cortical or cranial nerve signs, the possibility of lower medullary/upper cervical cord pathology was considered. Historical clues for a vertebral artery dissection were negative, including chiropractic neck manipulation or recent neck trauma. A focused examination for possible medial medullary or Brown-Séquard syndrome was done; however, there was no involvement of the hypoglossal nerve or a crossed sensory pattern to cor- roborate the above clinical diagnoses. Further discussion with the neuroradiologist and a closer look at the CT angiogram revealed an area of hyperdensity within the cervical spinal canal (figure, A). An urgent MRI scan of the spine was done, which revealed an epidural hematoma extending from the inferior border of C2 to C5 causing cord compression that was predominantly located on the right (figure, B and C). An urgent C2-C4 laminectomy was done with evacuation of the blood clot. A bleeding epidural vein was seen adjacent to the clot. Postoperatively the patient underwent rehabilita- tion with subsequent improvement of her neurologic deficits. DISCUSSION Stroke syndromes commonly present as hemi-sensorimotor deficits with a varying combination of other neurologic signs. 1 Large hemispherical strokes are frequently associated with cortical signs such as language dysfunction when the dominant hemisphere is involved or visuospatial abnormalities when the nondominant hemisphere is involved. Subcortical stroke syndromes involving the centrum semiovale can present with differential weakness of the upper and lower extremities depending on the arterial territory involved, whereas those involving the internal capsule present with dense deficits. Brainstem stroke syndromes are classically associated with crossed hemiparesis wherein there are ipsilateral cranial nerve signs and contralateral corticospinal signs. Two rather uncommon causes of a hemi- sensorimotor syndrome with minimal to absent From the Division of Neurology, Department of Medicine (J.V., T.H.L.), Departments of Diagnostic Imaging and Medicine (E.T.), and Division of Neurosurgery, Department of Surgery (C.N.), National University Hospital, Singapore. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. © 2016 American Academy of Neurology e45 ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.