Case #1
Stroke
Annie Hargrave
One Liner:
HPI: 68M with h/o HTN, DM is BIBA when he was found down by his wife. She
states that she last saw him normal 1 hour ago when he was washing the dishes
after dinner. She found him on the floor, unable to move his arm or leg. He could not
speak and look confused. She called 911.
Ask for more history questions: For example 1. Did he lose consciousness? Not sure, she did not see it
2. Did he have urinary or bowel incontinence? No
3. Did he bite his tongue? No
4. Has this happened in the past? No
5. Had he had a HA? No
6. Is he on insulin or any other hypoglycemic?
PMH: HTN, DM once told that he had a “strange heart beat”
Med: HCTZ, metformin – not compliant for the last year
All: penicillin
Sx: Recently moved and has been dealing with the death of his grandson so he has
not been to see a physician in about a year.
HRB: smokes 1ppd x20 year, 1 beer at night, little exercise
DDX: Unprovoked Fall with AMS
(1) Stroke (Hemorrhagic vs Thrombo-embolic)
(2) Seizure with Todd’s Paralysis
(3) TIA – last warning, increased risk of stroke in the next week – Use ABCD^2 score
to calculate risk
(4) Hypoglycemia
(5) Syncope
Todds Paralysis – focal area of weakness after a seizure that usually affect the
appendages, but can also cause speech deficits. Usually subsides within 48hrs for
partial focal seizure or focal that generalizes.
Hemorrhagic – HA that gradually worsens
Thromboembolic – Often sudden onset of maximum severity of symptoms +/- HA
TIA – transient blockage of an artery. By definition, neurological symptoms much
last less than 24 hours.
Exam:
Gen: lethargic, confused thin man
HEENT: normocephalic, atraumatic, tongue without lacerations, PEERL but gaze
preference towards the side of the left (location: frontal eye fields)
CV: irregularly, irregular beat, tachycardic, no mumers
Pulm: CTAB
Abd: Non-TTP, BS present
GU/GI; no incontinence
Neuro:
Mental status: lethargic, not answering questions or following commands
Cranial Nerves: Facial nerve: Right face weakness of lower half – able to lift eye
brows (motor cortex – UMN)
Motor: Right arm weakness > right leg weakness (motor cortex)
Sensory: Right loss of temperature, light touch and proprioception (sensory cortex)
Broca’s Aphasia (posterior frontal lobe)
Extremities: Babinski sign present
Location?
Left MCA (Superficial Division) – Review
Data:
Non-Con HCT: negative
CBC: slight leukocytosis otherwise wnl
Chem 7: WNL
Blood glucose
PT/PTT/ INR: WNL
*if woman – urine pregnancy test
F.A.S.T. is an easy way to remember the sudden signs and symptoms of a
stroke:
Face Drooping
Arm Weakness
Speech Difficulty
Time to call 911
NIH Stroke Scale: Use to quantify the impairment caused by a stroke.
1. LOC (alert, not alert but responsive, not alert but responsive to painful stimuli,
unresponsive.)
2. Horizontal Eye Movements (Normal, partial gaze palsy, total gaze paresis)
3. Visual field test
4. Facial Palsy
5. Motor Arm (pronator drift – watch 10 s)
6. Motor Leg
7. Limb Ataxia
8. Sensory
9. Language
10. Speech
11. Extinction and Inattention
Score [3]
0
0-4
Stroke Severity
No Stroke Symptoms
Minor Stroke
5-15
Moderate Stroke
16-20
Moderate to Severe Stroke
21-42
Severe Stroke
 16 indicates a strong probability of patient death
 <6 – strong probability of a good recovery
Tissue Plasminogen Activator (tPA) (enzyme that catalyzes the conversion of
plasminogen to plasmin)– window period ~3hrs. Some patients can receive it up
to 4.5 hours.*
Absolute Contraindications:
Intracranial Hemorrhage on CT
Clinical presentation suggestive of SAH
Neurologic surgery
Head trauma
Previous stroke in past 3 months
Uncontrolled HTN (>185mmHG SPB or >110mmHg DBP)
h/o intracranial hemorrhage
seizure at stroke onset
AVM/neoplasm/aneurysm
active bleeding
endocarditis
bleeding diathesis (low platelets, heparin w/in 48 hrs, INR >1.7, use of direct
thrombin inhibitors)
Glucose <50 or >400 mg/dl
Antidote: aminocaproic acid
Mechanical Thrombectomy : associated with reduced mortality in a meta-analysis of
53 studies. Generally used in patients that cannot receive fibrinolytic therapy or
who do not improve with the interview. Can be administered within 6 hours of
receiving tPA. (MERCI tril)
*cannot be >80y/o, have h/o prior stroke and diabetes, be on anticoagulant –even if
INR <1.7, NIHSS>25, CT with multilobar infarct
Management:
- ABC’s
- IV tPA within 3 hours
- Parenterally administered anticoagulants (heparin, LMW heparins) are
associated with increased risk of serious bleeding complications
- There is not sufficient e/o the efficacy of anticoagulants in potentially high
risk groups i.e. those with cardioembolic stroke.
- If e/o cerebral edema – papilledema, nausea, HA or imaging changes, give
mannitol , hyperventilate and raise the head of the bed to decrease ICP.
-
Permissive HTN – want to keep perfusing the brain but don’t want to cause
reperfusion damage. Therefore lower BP slowly.
Stroke Syndromes:
ACA: contralateral hemiparesis and sensory deficits weakness legs >arms. Apraxia
(motor cortex and corpus callosum infolved), urinary incontinence (pelvic floor
muscularure), anosmia
PCA: acute vision loss, confusion, paresthesia, posterior HA, dizziness, nausea,
memory loss
Brainstem lesions – Look for cranial nerve deficits
Cord lesions – look for (1) sensory mismatch – temperature contralateral to dorsal
column and motor loss. (2) dermatome and myotome lines designating lesion
Types of Aphasia:
Broca’s (expressive): left posterior-inferior frontal lobe - expressive aphasia
Wernicke’s (receptive): left superior temporal lobe – word salad
Conduction: fluent aphasia with impairment with repetition involving the arcuate
fasiculus and left parietal region.
Risk Factors for Stroke:
HTN
DM
Smoking
inactivity
Atrial Fibrillation – irregularly irregular heart beat. Can be persistent or paroxysmal.
Carotid artery stenosis :carotid endarterectomy -for asymptomatic patients with
stenosis greater than 60%
Epidemiology:
Stroke is the third leading cause of death in the US and the leading cause of adult
disability
Causes 200,000 deaths or 1 out of 16 deaths per year in the US
Ischemic stroke composes 80% of all strokes