21st June 2023

A 72-year-old woman comes into A&E with dense right-sided hemiplegia, facial droop and right homonymous hemianopia

A 72-year-old woman comes into A&E with dense right-sided hemiplegia, facial droop and right homonymous hemianopia. She also has dysarthria. Her NIHSS (National Institutes of Health Stroke Scale) is 12 on admission. She is out of the window for thrombolysis.

She has a past history of Parkinson’s disease, hypertension, reflux, and colon carcinoma. She is currently taking ramipril, amlodipine, omeprazole, Sinemet and entacapone.

CT head shows a large left middle cerebral artery (MCA) infarct.

She is found to be severely dysphagic and is made nil by mouth. As a result, she is started on an equivalent dose rotigotine patch.

The patient was given an aspirin 300mg suppository. The patient had a BP of 220/150 mmHg, so a GTN infusion was started to reduce BP to a target of 140/90mmHg.

The next day when seen by the Stroke Consultant on ward round, she is found to be drowsy and to have worse dysarthria. The Stroke Consultant calls Radiology to order an urgent repeat CT head.

What is the most likely cause of her presentation the next morning?