A 28 yo white f comes to ER very anxious. She woke up this m

[madhurima]

A 28 yo white f comes to ER very anxious. She woke up this morning with severe weakness over the right side of her body. The weakness came on all of a sudden, but gradually resolved during the day. She denies any sensory symptoms. Her boyfriend reports that her speech was "weird, almost as if she was stuttering or struggling to get her words out". This too has resolved. The patient denies any other symptom. The only other history is that she returned from a holiday in Italy 2 days ago. Vitals are unremarkable. The neurological exam is normal. Her CXR withing normal limits. EKG shows normal sinus rythm, with a rate of 82/min. Urgent CT within normal limit. Which of the following investigations is most likely to reveal the underlying cause of this episode?

a. Carotid Doppler USG

b. MRI of head

c. Psychiatric referrel

d. Transthoracic echocardiogram

e. Cerebral angiography

[madhurima]

D . Its TIA, Ischemic stroke are not always visible on CT within 24 hours of presentation, so her CT is normal. In elderly atherosclerosis and emboli are most common. Doppler USG of carotid can be done in that case. In young patient, atherosclerosis is unlikely, and in absence of other causes (such as vasculitis, arterial disscetion) , embolism is considered the mostly likely in young age group. Emboli in young patients mostly likely originate in the heart, embolism can occur in the setting of vulvular disease, cardiac arrythmia, infective endocarditis or atrial mysoma. To identify the cause, thransthroracic echocardiogram is done. If normal, further work up for hypercoagulable conditions can be sought. In this patient, transatlantic flight put her in increased risk of venous thrombosis.