A 64-year-old man is brought to the emergency department after suddenly struggling to communicate earlier that day, substituting words with unrelated ones and speaking in fragmented, incoherent sentences during a conversation with his wife.

On examination, the patient is alert and appears aware of his surroundings. He understands spoken language and is able to follow simple commands, but is unable to articulate his thoughts coherently. Power, tone and sensation of the upper and lower limbs are intact. Cranial nerve examination is unremarkable.


Which of the following is the most likely diagnosis based on the Bamford classification system?

Options:
explanation: This vignette describes a sudden onset of isolated non-fluent (expressive) aphasia, representative of partial anterior circulatory syndrome (PACS). Lacunar stroke is characterised by small subcortical infarctions in the deep structures of the brain. It usually manifests with pure motor or pure sensory deficits, ataxic hemiparesis, dysarthria-clumsy hand syndrome, or other focal neurological signs without significant language or cognitive impairment. This patient's symptoms are not consistent with a lacunar stroke, as they involve language and communication difficulties.
name: Lacunar syndrome
label: b
answer: no
explanation: This vignette describes a sudden onset of isolated non-fluent (expressive) aphasia, representative of partial anterior circulatory syndrome (PACS). Lacunar stroke is characterised by small subcortical infarctions in the deep structures of the brain. It usually manifests with pure motor or pure sensory deficits, ataxic hemiparesis, dysarthria-clumsy hand syndrome, or other focal neurological signs without significant language or cognitive impairment. This patient's symptoms are not consistent with a lacunar stroke, as they involve language and communication difficulties.
name: Posterior circulatory syndrome
label: d
answer: no
explanation: This vignette describes a sudden onset of isolated non-fluent (expressive) aphasia, representative of PACS. A diagnosis of TACS needs to fulfil **all** of the following:
 

 * Unilateral motor and/or sensory deficit of the face, arm and leg
 * Homonymous hemianopia
 * Higher cerebral dysfunction
 

 In this case, only higher cerebral dysfunction (aphasia) is fulfilled.
name: Total anterior circulatory syndrome
label: c
answer: no
explanation: This is the correct answer. This vignette describes a sudden onset of isolated non-fluent (expressive) aphasia. Higher cerebral dysfunction such as visuospatial disorder or aphasia (in this case) in the absence of hemiplegia/hemiparesis, and homonymous hemianopia, is classified as PACS.
name: Partial anterior circulatory syndrome (PACS)
label: a
answer: yes
explanation: Basilar artery thrombosis is a type of ischaemic stroke that occurs when there is a blockage in the basilar artery, a major blood vessel at the base of the brain. Common symptoms of basilar artery thrombosis include impaired consciousness, paralysis of the face and limbs, difficulty speaking, and vision problems. It can also result in the dysfunction of cranial nerves, which may cause facial weakness and impaired eye movements. It typically does not present with isolated language and communication deficits.
name: Basilar artery thrombosis
label: e
answer: no

Correct answer: a

Partial anterior circulatory syndrome (PACS)