This article is going to be technical - for medical students. You can find everything from Onset to Prognosis here.
At Home :
A 67 year old male patient was brought to the ER with sudden loss of movements of the Right Arm and slurred speech. He was last seen normally by his wife an hour ago. Then he suddenly felt uneasy, couldnt speak properly (slurred) and was not able to move the right arm.
The Ambulance was called by the Wife who saw him on the Floor.
The Hospital :
The Patient was brought to the Hospital with a Suspicion of an Acute Cerebrovascular Accident or simply put, a Stroke.
What kind of Stroke is it?
Ischemic or Haemorrhagic?
How to localise the lesion even without a CT or MRI?
Is a thorough History important in Stroke?
Whats the Treatment?
What happened to the Patient?
- Immediatley after being brought to the ER, the doctor on duty did alert the Radiology department for a CT/MRI scan.
Then Doctor looks for FAST - Face - Arm - Speech - Time. (you can check - How does Stroke look like for on my page basics on Stroke)
On quick examination of cranial nerves - The doctor found that patient is not able to show his teeth or fill his cheeks with air properly on the right side of his face. He could close is both eyes tightly. This was mild a central Facial Paralysis.
How to differentiate a central and peripheral facial palsy? I will write it in a future post.
On further examination the doctor also found that the patient could not move his right arm. It was almost like a dead peace of meat.
How to localise the Lesion without MRI/CT ?
Firstly no Headache and no increasingly worsening symptoms suggest that this might not be a haemorrhagic stroke. But still we can only rule this out through imaging.
For localising a lesion, the doctor must be well equipped with blood supply of the brain. As the symptoms are on the right side - the lesion should be most probably on the left Cerbral hemisphere or left side of the Brain stem. Arm involvement suggests a middle cerebral artery involvement. This is a likely case of left MCA infarction.
How to take proper History and Examination in such acute cases?
Its better to follow a Pattern - it would be better if I dedicate a complete Post to it.
In this case the Doctor takes a small and precise History. Remember Stroke is an Emergency - we cannot waste time here. Because "Time is Brain"
There is concept called "Door-to-Needle time" in Stroke - which is the time from the arrival of stroke patient in emergency to initiation of recombinant tissue plasminogen activator (rt-PA) drug therapy. It is under 30 minutes for a CT based Thrombolysis and under 40 minutes for MRI based Thrombolysis.
So, we take a precise and short history.
When did the Symptoms start to appear? or If its not clear, when was the Patient seen normally last time?
In this case, the was seen in a normal condition an hour ago - and the Patient was brought to ER within an Hour.
This should make the Doctor actually happy. Because this is within the Time Window of Stroke. **even within the Time window - the sooner-the Better. There is a good chance that the Patient will recover if everything falls in place -
The goals in the initial phase include:
- The ABC´s of emergency medicine - airway, breathing, and circulation - secure them - in this case the Patient is stable.
- Determining if patients with acute ischemic stroke are candidates for intravenous thrombolytic therapy or endovascular thrombectomy.
This can be done through a thorough checklist (a quite interesting one) and also an MRI.
In this case an MRI Cranium along with MR Angiography was ordered.
The result showed an Acute Ischemic lesion in area in the Territory of left middle cerebral artery. In the Angiography there was a embolic blockage of left MCA in M1 segment. There is also a Aterosclerotic plaque which is blocking most of the Internal Carotid Artery on the Left side.
After ruling out all the possible CONTRAINDICATIONS - Intravenous Thrombolysis was done.
Important thing to note here is - Explaining the Treatment and taking consent of the Patient. Because even after ruling out all the Contraindications - its still a very dangerous treatment - it increases Bleeding chances, as it is a Thrombolytic therapy.
I will give you an easy Checklist for choosing whether to go with Thromboslysis or not in a different article.
The Patient was given a specific dose of rtPA (recombinant tissue plasminogen activator) - 90% of the Body weight - the Patient weight 80 kilograms - he got a dosage of 72 mg rtpa. That too divided - 10% as bolus and remaining 90% as an Infusion over an hour.
As the Patient had an embolic Blockage of an intracranial artery - Neuroradiology department was contacted for a a possible Angiography and revascularisation of the left Middle Cerebral Artery. Its called the Digital Substraction Angiography to look at all the blood vessels of the Brain.
The Patient was intubated for this procedure - as it was done under a general anesthesia. In this Procedure - the Embolus was removed and Endovascular revascularisation was made possbile through a mechanical Thrombectomy.
They even placed two stents - one in the left MCA - M1 segment and one in the left Interal Carotid Artery.
Then after stabilising the Patient - he was extubated and sent to the Stroke Unit for further monitoring.
The Stroke-Unit :
Stroke Unit treatment is called as a complex treatment Regimen including Monitoring of ECG, BP and SpO2 and also adjuvant Treatments of Physiotherapy, Ergotherapy and Logopedy according to requirement
s.
Usually the Monitoring takes place for 72 hrs with a goal of uncovering the pathophysiologic basis of the patient's neurologic symptom.
In this case In our 72 hrs - we monitored the Patients ECG, Blood Pressure and did a CT review Examination after 24 Hrs of Thrombolysis and Thrombectomy.
ECG is important to rule out any possible Atrial Fibrillation - A.Fib is major cause of Cardiac Embolies. The Patient didnt have any.
BP was Monitored and was put strictly under 140 mm Hg Systolic Pressure to ensure no further Haemorrhages after the Treatment.
CT Review showed no haemorrhagic transformation of the lesion.
Further investigations of Duplex Ultrasonography - extracranial and transcranial blood vessels to rule out any further stenosing arteries and veins, Echocardiography - in come cases a Transoesophageal Echocardiography is required to rule out any Thrombus/ Vegetaion from the Heart - particularly left Atrium or Mitral Valve.
A 24 hr long ECG might be useful in a doubtful case of Atrial Fibrillation.
In this case the Etiology was - Atherosclerotic plaque from the Internal Carotid Artery i.e., Arterio-arterial type of Stroke. Where a Thrombus from a big artery is responisble for an embolic block in the brain.
The Clinical Picture :
Lets look at the Patient clinically now - I was concentrating entirely on what was done as treatment modalities for the Patient.
But lets see clinically
The Patient was brought with - inability to move righr Arm, slight Facial droop right sided and Slurred speech.
He could understand us - was oriented to time, place and Person. Head and neck were not stiff, Cranial nerve Examination showed no abmnormalities except for Facial Paralysis on the right side. There was no headache, no Vomitings or Nausea. No History of Trauma.
He said, as he was brushing his teeth - he wasn´t able to move his right arm all of a sudden. Then he was confused and called his wife - by the time she came - he sat on the Bathroom Floor stressed in Angst.
His wife reacted quickly - calling the Paramedics and bringing him to the Hospital. In the Hospital - he completely lost ability to move his arm and developed a slight facial droop.
What happened in the End? Prognosis:
After the Thrombolytic treatment and Thrombectomy with Stent implantation - the symptoms disappeared. The Patient was lucky enough to get back his strength and speech in a very short period of time. The National Institute if Health Stroke Score was 15 on Admission - after Treatment and 2 Days - it came down to 0!
The Patient was put on dual Antiplatelet Therapy with Aspirin and Clopidogrel for the next 3 months and then Aspirin life long. The dual Antiplatelet Therapy was because of the two stents he received. He was also started with a Statin to keep the LDL levels in check. Antihypertensive Treatment was also initiated.
I will come back with basics of Neurological Exam and History taking - along with a lot of case studies like this in the middle.
Whenever i find some interesting topic - i will give a good overview of it too... Let me know if you want to read something interesting or complicated in as simple way...
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