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Metabolic syndrome complicated by carotid non embolic TIA due to affection of superior branch of middle cerebral artery As there's aphasia , contralateral paresis with NO visual symptoms. moderate risk according to ABCD2 score (5 points A» 0 B » 1 C » 2 D duration » 1 D diabetes » 1 الاسم عمر شريف الرقم مش عارف اكتبه كل شوية اليوتيوب يمسح الكومنت

HUS ??

The Missing point in the diagnosis: 1- heavy smoker: increases risk of vascular damage or play significant role in worsening atherosclerosis and vascular damage lead to vascular luminal narrowing 70 % lead to TIA 2- The ABCD² Score to estimate or predict the risk of stroke following TIA : In this cases : 0 (age ) + 1(BP ) + 2 ( clinical features or unilateral weakness) + 0 ( Aphasia) + 1 ( diabetes) + 1 ( duration) = 5 This patient has moderate risk of stroke ( 4 % in 2 days ) Admission to hospital to observation , follow up and Urgent evaluation and management . 3- determined to affected area or blood vascular: inability to speak ( aphasia) results affecting in the Broca's area and the left middle cerebral artery supplies Broca's area in frontal lobe and Wernicke's area in the temporal lobe , both of which are critical for speech production and comprehension. -Cerebral blood vessels spasm

Missing point: ABCD² score: in this case 5 points ( moderate) . Heavy smoker . Weakness occur while at work. Vascular artery that affected ( left middle cerebral artery) . Lacunar stroke due to hypertension ( most common cause) . Lenticulostriate branches arteries . Atherosclerosis in carotid or it's branches arteries

Prognosis ( According to ABCD2 score) 5 points in this patient This patient is Moderate risk to develop stroke ( Age(0)- BP(1) - Unilateral weakness(2) - Duration(1) - Diabetes(1) ) David Emil Efraim ديفيد اميل افرايم كل ما اكتب رقم التليفون التعليق يتمسح

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The symptoms described in this patient suggest the involvement of the left middle cerebral artery (MCA) territory, which supplies specific regions of the brain responsible for motor function and language. Key Findings Supporting Left MCA Territory Involvement: 1. Right-sided weakness (right upper and lower limbs): The primary motor cortex (precentral gyrus) located in the frontal lobe is affected. The left hemisphere controls the motor function of the right side of the body. The upper limb and face are predominantly represented in the lateral aspect of the motor cortex supplied by the MCA. 2. Inability to speak (aphasia): The Broca's area (in the dominant hemisphere, typically left in right-handed individuals) is involved. The left MCA supplies Broca's area in the frontal lobe and Wernicke's area in the temporal lobe, both of which are critical for speech production and comprehension. In conclusion what was affected in this patient Motor cortex: Causing contralateral (right-sided) weakness. Broca's area: Causing expressive aphasia (inability to speak). This pattern in this patient strongly suggests an ischemic event in the left MCA superior division, which supplies the lateral frontal lobe, including the motor cortex and Broca's area. الاسم محمد أحمد عبدالله محمد رقم التليفون 01090160039

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A missing point in the diagnosis could be dyslipidemia. Reasoning: Patients with metabolic syndrome, obesity, diabetes, and hypertension, especially those who smoke heavily, often have underlying dyslipidemia, characterized by: Elevated triglycerides Low HDL cholesterol Elevated LDL cholesterol Small, dense LDL particles that are more atherogenic Dyslipidemia is a key contributor to atherosclerosis and increases the risk of ischemic stroke and TIA, particularly in the setting of non-cardioembolic TIA, which is often due to atherosclerosis of the carotid or cerebral arteries. Suggested Additions to the Diagnosis: Dyslipidemia (likely atherogenic dyslipidemia) Atherosclerosis, especially of the carotid arteries These additions complete the picture of vascular risk factors leading to the patient's TIA. Name:- Mohamed Mohamed ali Tel:- +201092100689

بارك الله فيك د. شريف❤

The missing point in the diagnosis may refer to a possible underlying cause or risk factor that has not been explicitly addressed. Possible Missing Points: 1. Dyslipidemia: Often associated with metabolic syndrome, which includes elevated triglycerides and low HDL cholesterol levels. These contribute to atherosclerosis, increasing the risk of TIA. ★ hypertension, diabetes or lipohyalinosis can predispose to microvascular dysfunction or stenosis of the lenticulostriate branches arteries. ( Left middle cerebral artery) 2. Carotid Artery Atherosclerosis: A key factor in carotid TIA. Plaque or stenosis in the carotid arteries could be contributing to the transient ischemia. 3. Lifestyle Factors: Heavy smoking: Increases the risk of arterial damage and thromboembolic events. Smoking, which is already mentioned, plays a significant role in worsening atherosclerosis and vascular damage. 4. Family History: If there is a family history of cardiovascular disease or stroke, it could further support the risk profile. 5. Sleep Apnea: Obesity (BMI 35 kg/m²) and large waist circumference suggest a potential for obstructive sleep apnea, a condition linked to hypertension and increased cardiovascular risk. ( Syncope) ★ lacunar stroke because hypertension and diabetes . Addressing these points through further investigation (e.g., glucose, electrolytes , coagulation profile, lipid profile, and would provide a more comprehensive assessment of the patient's condition Imaging Studies: MRI Brain with DWI (Diffusion-Weighted Imaging): To rule out small infarctions that may indicate a minor stroke. CT Angiography or Carotid Doppler Ultrasound: To detect stenosis, plaque, or arterial dissection in the carotid arteries. ★Prognosis or The ABCD² score is used to estimate the risk of stroke following a Transient Ischemic Attack (TIA). Here's how it is calculated for this patient: Total ABCD² Score : 0 (Age) + 1 (BP) + 2 (Clinical Features) + 1 (Duration) + 1 (Diabetes) = 5 This patient has a moderate risk of stroke (4% in 2 days), and urgent evaluation and management are required. Exclude of Differential Diagnosis: Although TIA is the most likely diagnosis, other conditions should be considered: Hypoglycemia: May mimic stroke-like symptoms because in this cases patient diabetes may be increased taking insulin or antidiabetic drugs or no eating lead to hypoglycemia but usually accompanied by systemic symptoms like sweating, confusion, or loss of consciousness. 2. Focal Seizure with Todd’s Paralysis: Focal weakness after a seizure, but speech difficulty and rapid resolution favor TIA. 3. Migraine with Aura: Can cause transient neurological symptoms, but often associated with headache and sensory disturbances.

1. Functional Diagnosis: TIA is characterized by temporary neurological dysfunction without lasting deficits but with (a MODERATE RISK) score of 5 for developing stroke according to The ABCD2 score as follows: • Age: 0 points. • Blood Pressure: 1 point. • Clinical features: 2 points (unilateral weakness). • Duration: 1 point • Diabetes: 1 point 2. Etiological Diagnosis: The most likely etiology is noncardioembolic atherosclerotic thromboembolism according to the patient’s risk factors: Hypertension, diabetes, and smoking. 3. Anatomical Diagnosis (Site of the lesion ): The left hemisphere of the brain in the middle cerebral artery (MCA) the main artery, not the branches as it affects more than one area away from each other 1-Contralateral hemiplegia 2-Aphasia 4. Pathological Diagnosis: - Transient ischemia caused ATH narrowing of the MCA branch of the carotid system due to plaque formation. Clinical diagnosis is transient Hemiparesis in a metabolic syndrome patient due to TIA in the form of transient hemiparesis (right-sided weakness) and aphasia due to temporary ischemia in the left middle cerebral artery (MCA), likely caused by noncardioembolic atherosclerotic thromboembolism resulting from the patient’s hypertension, diabetes, and smoking. The ischemic event is due to the narrowing of the MCA due to atherosclerotic plaque formation in the carotid system. The patient has a moderate risk of stroke, with an ABCD² score of 5, indicating a need for urgent evaluation and management. عبدالرحمن محمد الرفاعي 01013946192

I think this is lacunar stroke affect deep branch of basal ganglie because pure motor symptoms and mild weakness

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I think the missing part in the diagnosis is the actual cause behind the TIA which is probably carotid artery stenosis or atherosclerosis affecting the carotid artery as the given history shows the patient is male 57 yrs old smoker diabetic hypertensive and experienced TIA attack ( aka symptoms of ischemia ) obese class 2 ( severe obesity) diagnosed metabolic syndrome , which strongly suggest atherosclerosis but for sure we need important further investigation to confirm dx as carotid doppler US which i assume is the first investigation to order in this patient after Brain CT to exclude haemorrhagic stroke also MRA and CTA may be done to evaluate accurately the extent of the atherosclerosis and carotid stenosis and if we suspect a ischemic stroke after exclusions of hge by brain NCCT we can perform a contrast enhanced brain MRI to show the exact level of the stroke if present and sure he will need a full lab ABG lipid profile electrolytes My name is : Ahmed Fahmy Sharaf Phone No. : 01068259735 This comment is written on 22th jan 2025 at 7:25 PM

I think the missing part in the diagnosis is the actual cause behind the TIA which is probably carotid artery stenosis or atherosclerosis affecting the carotid artery as the given history shows the patient is male 57 yrs old smoker diabetic hypertensive and experienced TIA attack ( aka symptoms of ischemia ) obese class 2 ( severe obesity) diagnosed metabolic syndrome , which strongly suggest atherosclerosis but for sure we need important further investigation to confirm dx as carotid doppler US which i assume is the first investigation to order in this patient after Brain CT to exclude haemorrhagic stroke also MRA and CTA may be done to evaluate accurately the extent of the atherosclerosis and carotid stenosis and if we suspect a ischemic stroke after exclusions of hge by brain NCCT we can perform a contrast enhanced brain MRI to show the exact level of the stroke if present and sure he will need a full lab ABG lipid profile electrolytes My name is : Ahmed Fahmy Sharaf Phone No. : 01068259735 This comment is written on 22th jan 2025 at 7:25 PM

انتصرت ايه !!! ... قطاع غزه اتساوا بالأرض ده غير ال ٥٠ الف او يزيد اللي ماتو !!

الدكتور شريف الهواري المحترم اوي ❤

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A case of metabolic syndrome (as evidenced by abdominal obesity, hypertension and diabetes) complicated by a left non cardioembolic atherosclerotic (as evidenced by the non modifiable risk factors of: 4th to 6th decade male, and the modifiable risk factors of: hypertensive, diabetic, heavy smoker, central obesity) carotid artery TIA affecting the left middle cerebral artery, 
he has a risk stratification score of 5 (moderate risk) of developing a stroke according to the ABCD2 scoring system. 
Other differential diagnosis of Transient hemiplegia should be excluded as Todd’s paralysis, DS and hemiplegic migraine. John Emil Awad NB: whenever I put my phone number youtube deletes the comment unfortunately

the main missing point is this Diagnosis is the Anatomical diagnosis (levelling ) or in other words where is the lesion ? *** the lesion occurred at cerebral-subcortical ( Corona radiata ) on the left hemisphere *** presence of complete complete complete rt hemiparesis from the start and Aphasia suggests subcortical hemiplegia and by which we can also exclude other possible diagnoses: 1) Cortical hemiparesis ( which start as monoplegia not hemi but it may or may not ... may or may not progress to hemiplegia) 2) Capsular hemiparesis which easily excluded by aphasia which is a cortical sign. And if it was a complete artery occlusion of MCA the both upper and lower limbs will be affected simultaneously but upper limb is more affected than lower but here in the case both limbs are affected to the same extent !! Other missing points in the diagnosis include Clinical diagnosis , prognosis and the affected artery as following • Clinical : complete right hemiparesis with aphasia • Prognosis : the patient has a moderate risk for developing Stroke : According to ABCD2 Score : A= 0 B = 1 C= 2 D duration = 1 D diabetes = 1 the patient score = 5 which interpretated as moderate risk for developing stroke. • And the affected artery is left Middle Cerebral Artery طبعا مفيش فرق بين hemiparesis and hemiplegia الفرق بس فال severityyy الاسم : عبدالرحمن محمود عبدالله الموبايل : 01155446105

A transient ischemic attack (TIA) is often referred to as a "mini-stroke." It involves a temporary disruption of blood flow to the brain, causing stroke-like symptoms that typically resolve within 24 hours. TIAs serve as a warning sign for a potential future stroke. Proper diagnosis usually requires a medical professional to evaluate symptoms, which may include sudden numbness or weakness, confusion, trouble speaking, or loss of balance. Immediate medical attention and further diagnostic tests such as imaging (MRI or CT scans) or ultrasound of the carotid arteries are essential to confirm the diagnosis and prevent future complications.

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TIA Carotid type Non-Cardioembolic. I think the missing point in diagnosis is the level of ischemia"which part is affected" 1- *If it was Cortical ischemia it's usually monoparesis or monoplagia* and the case is hemiparesis. 2-If it was crona radiata ischemia... stmilar to Cortical. These areas to be affected and cause hemiparesis... need ischemia of large part of Cortex or Crona radiata and the patioat Conscious level may be disturbed at this time. 3-If it was internal Capsule ischemia "where fibers are Combact "...usually lead to hemiparesis"incomplete whit no facial affection as facial nucleus is bilaterally supplied"...and in this Case patient was unable to to speak at all due to affection of speech area but if was due to facial affection,it would be dysarthria. *So, findings support ischenta of internal capsule .* 4-If ischemia was in the brain stem... Hemiparesis with facial affection due to Vertebro-basilar ischemia in form of dysarthria and we have already disproven it. Note: Aphasia means cortical affection but if it's purely cortical affection... would be associated with disturbed conscious level for example which is not mentioned in this case So,TIA due to MCA ischemia causing mixed cortical and subcortical affection.

From the risk factors this is large vessel disease not lacunar and we know this is non cardioembolic so mostly atherosclerotic to carotid transient blockage make hypoperfusion to it's branch mainly left middle cerebral artery (MCA) particularly its superior division(Supplies the frontal lobe including Broca’s area and parts of the motor cortex) is the most likely artery affected in this case given the right sided weakness and speech difficulty

21:20 🤍 The missing points are … ⭐️ Since TIA signs are attributed to an arterial territory of the brain, then it is termed Focal TIA (not diffuse and not mixed) 1️⃣ Ischemia localization: There are two theories, the first one is more likely and typical presentation than the second one which is rare and atypical presentation but possible … ⭐️First Theory: TIA is cortical ,supported by the presence of a cortical sign (aphasia) but it was not mentioned that there is a limb weakness predominance which is against cortical ischemia ⭐️ Second theory: TIA is subcortical capsular (internal capsule) and aphasia is subcortical due to ischemia of the white matter tracts interrupting cortical connections supported by the presence of dense hemiparesis (upper limb = lower limb) as limb predominance was not mentioned ✅ Bedside classification of aphasia and muscle strength assessment scaling to check if it is either brachial hemiparesis or crural hemiparesis or dense hemiparesis can help in ischemia localization 2️⃣ Pathophysiological diagnosis of TIA: Further identification of the mechanism of arterial blood flow interruption after exclusion of cardioembolism. ⭐️ According to the first theory: It is caused by large artery atherothrombosis ⭐️ According to the second theory: it is caused by type 1 “atherosclerotic” small vessel ischemic disease (lacunar) or medium sized arterial atherothrombosis “lenticulostriate branches of MCA” 3️⃣ Topographical diagnosis of TIA: ⭐️ According to the first theory: Inability to speak suggests a non-fluent type of aphasia which can be … 1. Boraca’s aphasia -> associated features include gaze paresis or deviation, Facio-brachial paresis with or without hemi-hypoesthesia and caused by superior division (M2 segment) of Middle cerebral artery MCA 2. Transcortical motor aphasia -> associated features include crural paresis more than arm paresis, frontal lobe syndrome with or without hemi-hypoesthesia and caused by Anterior cerebral artery ACA 3. Global aphasia -> associated features include face, arm, and leg hemiparesis, hemi-hypesthesia, homonymous hemianopia for optic radiations in MCA or amaurosis fugax in ICA. (caused by proximal MCA or ICA) ✅ Since global aphasia is excluded, then it could be boraca’s aphasia or transcortical motor aphasia. Patient complained from weakness of upper and lower limbs with no evidence of facial paresis which means superomedial part of the motor cortex strip is affected more according to motor homunculus -> therefore it suggests transcortical motor aphasia more. 🚨 So, Topography of TIA in according to the first theory would be the left Anterior Cerebral Artery (ACA) ⭐️ According to the second theory: it is internal capsular ischemia supported by dense hemiparesis (UL=LL) which can ,but atypically, cause motor “non-fluent” aphasia 🚨 So, Topography of TIA in such theory would be in the branches of the left MCA “lenticulostriate” or atypical presentation of lacunar syndrome (dense hemiparesis + motor aphasia) 4️⃣ Risk stratification: Canadian TIA scoring is superior to ABCD2 and ABCD2-I scoring systems but it is not applicable in this case due to lack of information so we can use ABCD-2 score but blood pressure measurement is not recorded so accordingly the risk of stroke at 2 days is 4 to 5 (moderate risk) 5️⃣ Exclusion of TIA-mimics: the presence of vascular risk factors + old age + negative symptoms + no positive symptoms + sudden onset of symptoms and complete resolve in 24 hours = all suggest TIA and exclude its mimics 🚨 Conclusion According to type of aphasia and hemiparesis… ✅ Crural hemiparesis with Transcortical motor aphasia: Cortical focal TIA due to left ACA atherothrombosis with moderate risk of stroke ✅ Dense hemiparesis with Subcortical aphasia: Subcortical capsular focal TIA in the internal capsule with moderate risk of stroke either due to … ➡️ type 1 “atherosclerotic” small vessel ischemic disease causing atypical lacunar syndrome ➡️ Artery atherothrombosis of lenticulostriate branches of left MCA Name: Youssuf Mohamed Youssuf Abdalla Mobile no.: 01013436433

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I hope to be that one Dr sherif ...that is my answer to your question ...indeed ( 2 ) very critical points are missed in that case ... First point ...male 57 years old and heavy smoker ...please we must do first ( C.T chest ) & second ( Tumor marker) ...to exclude presence or absence of ((( Bronchogenic carcinoma )))) plus probability of tumor spread to liver , brain , bone Second point ...this patient is (( Obese )) plus (( Non cardio-embolic )) ..so i must check his (lower limbs ) and do (( doppler lower limb)) to exclude ((( Varicose veins )) ... If Varicose veins present ...it will be cause of (( Non cardio-embolic )) Plus too additional very important point which is: we must do (( factor 5 Leiden)) test ... If there is mutation in (( factor 5 Leiden)) , this indicate we must modify his treatment plan as we need (( New anticoagulat)) as (( Rivarospire 10 )) as lifelong prophylactic protection against further embolism in the future ... That is My full answer ... Name : Islam hazem Mahmoud Telephone ( 01142087640 )

The missing part is risk stratification According to Canadian tia score Is a high risk patient for developing stroke Need more assessment measures to prevent stroke

the presence of Aphasia indicate that it was a cortical hemiparesis rather than capsular and the affected artery is the middle cerebral artery so, the full diagnosis will be (( Metabolic syndrome complicated by non cardioembolic carotid TIA affecting the middle cerebral artery and manifested by cortical hemiparesis ))

full diagnosis is Metabolic syndrome complicated by( TIA ) non cardiombolic TIA , associated with hypertenstion , DM , DYSLIPIDEMIA , and obesity

Risk of the developing stroke According to ABCDD score 5 moderate risk Lt carotid TIA DD migraine…

Affection of superior branch of middle cerebral artery With ABCD2 score moderate risk for admission and follow up ❤❤

Smoking cessation for completing of treatment plan as well as prevention

the missing part (affecting the dominant hemisphere which is in this case the left hemisphere as the patient suffer from a aphasia and contralateral (right) hemiparesis )

We need to exactly locate the site of the non-cardioembolic carotid TIA. As there’s aphasia & contralateral paresis with NO NO NO NO visual symptoms it’s mostly the superior branch of the MCA. We can be 100% sure by imaging (MRI).

We need to exactly locate the site of the non-cardioembolic carotid TIA. As there’s aphasia & contralateral paresis with NO NO NO NO visual symptoms it’s mostly the superior branch of the MCA. We can be 100% sure by imaging (MRI).

Missed part could would should be the site of occluded artery which in this case is the left frontal branch of middle cerebral artery due to presence of aphasia and right sided hemiparesis BUT the case doesn’t mention that the weakness in the upper limb is more than lower limb It can’t be ICA because there was no visual disturbances in the case. We also could mention ABCD2. It is moderate risk for developing stroke in this case

Metabolic syndrome complicated by carotid non embolic TIA due to affection of superior branch of middle cerebral artery moderate risk according to ABCD2 score (5 points) with recommended admission for further evaluation

The point that is left is the localization: superior division of the left middle cerebral artery

The missing is ICA TIA mainly due to atherosclerosis lumen narrowing