Clinical Reasoning: A 73-year-old man with recurrent aphasia, headaches, and confusion

Abstract

A 73-year-old man presented with sudden right-sided weakness, aphasia, and low-grade headache. Medical history was pertinent for obstructive sleep apnea, hypertension, diabetes, and dyslipidemia, for which he was appropriately treated, in addition to taking aspirin for primary prevention. Initial bloodwork, head CT, and vessel imaging were normal. MRI showed a nonenhancing, nonrestricting T2 hyperintensity in the left temporal lobe, in addition to multiple microhemorrhages (figure 1, A and B). Symptoms resolved within 24 hours and he was discharged on a second antiplatelet agent (clopidogrel). Three weeks later, a second episode of aphasia and right-sided weakness occurred, resolving within hours. He returned to the hospital the following day as symptoms recurred again. He had had been continually complaining of headaches, and his family had noted a gradual cognitive decline over the past month. Repeat bloodwork and erythrocyte sedimentation rate were normal. MRI demonstrated persistent microhemorrhages and superficial siderosis, worsening of the left temporal lobe subcortical changes, as well as diffuse leptomeningeal enhancement.