The Case
CC
Aphasia and R-sided hemiparesis
HPI
29yo FTM on testosterone cypionate, no other sig pmh, presents with worsening headache, expressive aphasia, and R sided hemiparesis. Pt had been having moderate L sided headache x 1 week prior to this presentation. No hx of headaches or migraines. Pt was at the theater with his sister, noticed some R sided hand weakness, but then was noted to have expressive aphasia by sister and brought to ED.
In ED pt had aphasia, R sided hand numbness, clumsiness, initial head CT negative, given tPA, and admitted to stroke unit. Over next 24 hours, pt had CT angiogram, MRI brain, MRV brain without evidence of ischemia, mass, or bleed. By this time aphasia and motor symptoms had resolved, although still with some headache.
Physical Exam
HR 45 BP 164/87 RR 22 SpO2 100% T 101.2˚
General Appearance: Alert, in no acute distress
ENMT: Atraumatic, moist mucus membranes
Cardiovascular: RRR no RMG
Pulmonary: CTABL
GI: No tenderness or guarding, no masses or hepatosplenomegaly on palpation
Extremities: Palpable pulses. No edema, clubbing, or cyanosis
Skin: No evident rash or skin breakdown, normal temperature on palpation
Psych: Appropriate affect
Neurologic: AAOX3, PERRLA, EOMI, Visual fields are intact to finger counting. There is no dysarthria. Hesitation with word finding, naming (able to say knuckle, not watch or pen), Difficulty following complex commands. Facial strength and sensation are symmetric and intact. Strength is 5/5 throughout without pronator drift. Sensation to temperature is symmetric. Finger-nose-finger is intact. There is no neglect.
Labs
CBC 9.7> 11.5/38<376 BMP 144/4.5/107/26/18/0.94<113 LFT 7.7/0.2/4.5/36/49/0.4/29 INR 1.1 Troponin 0.0 VBG: 7.325/51/37/26 lactate 4.37 CT head without IV contrast: No acute intracranial findings CT angio head and neck: no evidence of aneursym MRI brain with and without IV contrast: No evidence of acute infarction, intracranial hemorrhage or mass, no abnormal intracranial enhancement. MRI head: great cerebral veins, vein of galen, major dural sinuses are patent
Questions
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What is your differential?
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What other labs or studies would help you confirm this diagnosis?
DDX: TIA, toxic/metabolic encephalopathy, infectious encephalopathy, seizure, meningitis
Studies: LP with CSF studies, tox panel, culture (blood, urine, csf), veeg
DDX: TIA,Focal Seizure secondary to androgen use, Viral encephalopathy.
Studies: Serum Testosterone, Lumbar Puncture with CSF for gram stain, cell count, culture, EEG. Carotid Doppler and Echocardiogram.
Hemiplegic migrane
seizure, hemiplegic migrain, MS. Needs: EEG, LP. tox screen.
hemiplegic migraine, anything to do with testosterone ?? what was the final diagnosis?