In 300 words or less, using your own words, describe the pathophysiological events that have resulted inMr AA's presentation; in your answer include which cells were affected, and whether they suffered reversible or irreversible cell injury and the rationale for your decision. Refer to and quote Craft and Gordon's Chapter 4 "Altered Cellular Function", orPorther's Chapter 2 "Cellular Response to Injury"

History

Mr AA is an obese 69-year-old male. He is a semi-retired business manager, running an industrial shed storage facility. He has been married for 43 years, is a non-smoker, and drinks one glass of wine each night. Some years ago Mr AA suffered from mild depression for which he received treatment; however, he no longer requires therapy. Essential hypertension was diagnosed 20 years ago. There is no prior history of diabetes, elevated cholesterol or heart disease. Apart from an occasional stroll with his wife, he leads a relatively sedentary lifestyle. He visits his GP infrequently. Medications include irbesartan 150 mg once-daily. Mr AA's father died of a stroke, aged 58 and his mother suffered a myocardial infarct at age 64.

Case presentation

Mr AA presents to his GP complaining of left hand weakness with difficulty gripping a cup, left leg weakness and a noticeable limp. He mentions that the symptoms started approximately 48 hours ago. He was initially dismissive; however, his wife insisted that he present to the doctor.
Physical examination

A physical examination reveals the following:

Blood pressure: 158/98 mmHg
Heart rate: 75 bpm
Respiratory rate: 25
Temperature: 37°C
Left homonymous hemianopia
Left facial paresis
Left arm and leg hemiplegia grade 4/5
Hyper-reflexia on the left with an up going plantar
Immediate interventions and Investigations

Mr AA is transferred to the nearest hospital with a dedicated stroke unit for further investigations. In the ambulance, the paramedics insert a peripheral line and monitor his vital signs. At the hospital, a CT brain scan is performed (Figure 1). A 12-lead ECG reveals normal sinus rhythm and a carotid duplex ultrasound reveals no stenosis of the carotid artery bifurcation on either side ( Figure 2).

Additional Investigations and results

Blood glucose: 5.2 mmol/L

Random lipids:
 - Total cholesterol: 7.0 mmol/L
 - LDL: 4.5 mmol/L
 - HDL: 1.0 mmol/L
 - Triglycerides: 2.0 mmol/L

FBE: Normal
U&E: Normal

Progress and follow-up

Mr AA underwent seven days of inpatient rehabilitation prior to discharge. He was ambulant and capable of self-care activities. He returned to his GP for a follow-up review, one week after discharge. At this point his medical therapy involved low dose aspirin (150 mg/day), simvastatin (80 mg/day) and irbesartan (150 mg/day). His blood pressure on follow-up was 150/90 mmHg.