6.1.1.1 Acute headache attributed to ischaemic stroke (cerebral infarction)

Identification: Female patient, 72 years old, with a history of non-anticoagulated atrial fibrillation, dyslipidemia, and obesity.

History of Present Illness:

Reports sudden and intense headache (8/10) in the occipital region, associated with vertigo, nausea, and vomiting, for the past 3 hours.

Simultaneously, experienced loss of balance, diplopia, and dysmetria when trying to grasp objects with the left hand.

No prior history of similar headaches or recent head trauma.

Physical/Neurological Examination:

Cerebellar signs: Gait ataxia, dysmetria on finger-to-nose test on the left, horizontal nystagmus.

Other deficits: Mild dysarthria and hyporeflexia in the left upper limb.

NIHSS: 6 (score suggestive of posterior stroke).

Complementary Exams:

Urgent non-contrast cranial CT: No signs of hemorrhage, but slight hypoattenuation in the right cerebellum.

Confirmatory MRI: Diffusion restriction in the territory of the right posterior inferior cerebellar artery (PICA), confirming acute cerebellar infarction.