Stroke Cases for Year 2 Medical Students PDF

Stroke cases for year 2 medical students Simon Hervey (Consultant, Stroke Medicine)  85 year old right handed woman. Background hypertension. Usually independent.  Witnessed sudden onset right sided weakness and dysphasia at 16.30 Case 1  Arrival to A&E at 17.30  On examination dense right...

Stroke cases for year 2 medical students Simon Hervey (Consultant, Stroke Medicine)  85 year old right handed woman. Background hypertension. Usually independent.  Witnessed sudden onset right sided weakness and dysphasia at 16.30 Case 1  Arrival to A&E at 17.30  On examination dense right face/arm/leg weakness, sensory loss, severe mixed dysphasia and right homonymous hemianopia.  ECG shows sinus rhythm  Which of the following tests would you like now?  Blood pressure  Laboratory blood tests Case 1  Blood sugar  Chest x-ray  CT head  Blood pressure 170/90  Blood sugar 6.3 What can you see? What is the diagnosis?  CT shows thrombus in proximal left MCA  Diagnosis is left total anterior circulation stroke (TACS) Case 1  How would you manage this patient?  Aspirin and IV fluids and admit to stroke ward  Thrombolysis only  Thrombectomy only  Thrombolysis and thrombectomy  Repeat CT…  78 year old right handed man. BG hypertension, smoker, high cholesterol, type two diabetes mellitus.  Found by wife in the morning – collapsed in bathroom with left arm and leg weakness.  On examination dense weakness left arm and leg. No other neurological findings. Case 2  Could this be a stroke?  What else would you like to know?  Last seen well at 10pm the night before when he went to bed  BP 200/95  BM 7.8  CT… What can you see? What is the diagnosis?  CT shows subacute right lacunar infarct  Diagnosis (based on symptoms and imaging) is therefore a right lacunar stroke (LACS)  What would you do next? Case 2  Aspirin and IV fluids, and admit to stroke unit  Thrombolyse  Thrombectomy  What about that blood pressure (200/95mmHg)?  Let it run high – he needs it!  87 year old right handed woman. Background hypertension, AF (on warfarin), OA. Lives alone, independent.  Onset of speech disturbance and started bumping into things on her right according to husband, from around midday.  Arrival to A&E at 16.50  On examination receptive dysphasia and right homonymous Case 3 hemianopia.  Could this be a stroke?  Which part of the brain is affected?  What else would you like to know?  BP 190/100  BM 7.5  CT… What can you see? What is the diagnosis? How would you manage this patient?  CT show left temporoparietal haemorrhage  No midline shift but some mass effect  Management  Urgent prothrombin complex concentrate and vitamin K Case 3  IV fluids  Control BP; if remains >180/110 on over 2 consecutive readings. Use either labetalol, or GTN infusion.  Discuss with neurosurgeons  Stroke ward admission, with regular neuro obs  Stop warfarin  58 year old man, business manager. No past medical history. Usually fit and well, although lots of recent stress.  Started having difficulty speaking whilst at work, whilst in a meeting at around 10am. Colleagues called for ambulance.  Arrival to A&E at 11am. On examination, quite Case 4 distressed. Expressive dysphasia (unable to give history). No other focal neurological deficit. Quite photophobic and vomited once.  Could this be stroke?  What else would you like to know?  BP 140/86  BM 6.5  CT… What can you see? Would you like any more information?  Collateral from colleagues:  Prior to onset of speech problems he had started to Scenario 4 complain of ‘flashing lights’ in the periphery of his vision, with associated nausea. Then began to develop headache.  Has previously taken days off work due to severe headache  Diagnosis? Migraine  Can mimic stroke symptoms  Careful history needed  Check for other symptoms – headache, visual aura, nausea, photophobia, phonophobia  Ask if personal history of migraine  Consider triggers – lack of sleep, change in diet, stress, hormonal changes, weather, alcohol etc  Migraineurs are at increased risk of stroke; prolonged aura carries associated risk of migrainous stroke  45 year old man, normally fit and well  Recent viral illness, with sore throat, rhinorrhoea, and left earache. Symptoms started one week ago, and mostly improving though earache persists  After waking this morning, looked in mirror noticed Case 5 left facial droop. Also drooled from left corner of mouth when drinking cup of tea, and managed to get soap in his left eye when washing his face.  On examination in A&E, left facial weakness involving the whole of left side of face, including the forehead and with incomplete closure of left eye.  Observations and BM normal Bells Palsy  Key feature is LOWER MOTOR VII palsy (i.e. involvement of forehead/incomplete eye closure)  But can be subtle/difficult to differentiate sometimes  Gradual onset  Ask about recent viral illness, taste disturbance, headache, earache  Look for vesicles!  Management usually steroids for 1 week (with PPI cover), +/- aciclovir if signs VZV  76 year old man, with history of hypertension, type one diabetes, previous stroke and ischaemic heart disease  Elective admission for a coronary angiogram  Nil by mouth from midnight the day prior to procedure  On morning of angiogram, the nurse in charge notices that he has become very pale, clammy and slumped to the left hand side Case 6  A stroke call is put out, and on arrival you find the patient drowsy with a GCS of 13 (E3, M6, V4), clammy, tachycardic and a definite left sided weakness  Observations show a tachycardia (110bpm), with otherwise normal findings  On reviewing his drug chart, you notice that his usual morning medications have been held although insulin has been given  Are there any other bedside tests that you would like?  BM 1.2 Case 6  Treat with glucose/glucagon and monitor symptoms  DON’T MISS HYPOGLYCAEMIA – THIS IS A MEDICAL EMERGENCY!!! Left occipital tumour Case 7 72 year old woman with gradual onset headache and on examination a right homonymous hemianopia. Past medical history of breast cancer. Beware insidious onset, and always ask about red flag symptoms particularly if atypical history or relevant past medical history. Important stroke mimics  Seizures  Tumour  Migraine  Bells palsy  Hypoglycaemia  Sepsis (hypotension and cerebral hypoperfusion)  Subdural haemorrhage  Functional disorder