Case Report: Embolic Stroke

Case Report: Embolic Stroke

• 1.
  John  Martinelli   IM  Geriatric  Case  #1:  Stroke   SBMC     2/17/14           History  of  Presenting  Illness:     Mr.  H.B.  is  an  84-­‐year-­‐old  Caucasian  gentleman  who  was  admitted  to  the  SBMC  ICU   via  the  ED  due  to  sudden  onset  of  right-­‐sided  lower  facial  droop,  right-­‐sided  upper   and  lower  extremity  weakness,  and  aphasia  which  began  approximately  one  hour   prior  to  presentation.  He  experienced  a  similar  episode  the  day  before  lasting   several  minutes  which  subsequently  resolved.  In  the  ED  he  promptly  received   thrombolytic  tPA  therapy  per  protocol.  He  has  a  history  of  longstanding   hypertension,  diabetes  mellitus  type  II,  and  hyperlipidemia  for  which  he  is  currently   being  treated.  Medications  include  metoprolol,  metformin,  and  atorvastatin.  There  is   no  history  of  cardiovascular/coronary  artery  disease,  peripheral  vascular  disease,   stroke,  surgeries,  or  hospitalizations.     Physical  Examination:     Upon  admission  to  the  ICU,  Mr.  H.B.  was  awake  but  appeared  lethargic  and  not   oriented  to  time  or  place.  He  was  slightly  tachycardic  at  100bpm  with  otherwise   normal  vital  signs.  He  spontaneously  opened  his  eyes,  responded  to  verbal   commands,  but  could  only  verbalize  with  grunting  sounds.  His  Glasgow  Coma  Scale   (GCS)  rating  was  11.  Pupils  were  equal,  round,  and  responsive  without  evidence  of   afferent  pupillary  defect.  Extraocular  muscles  were  full  and  orthophoric.  Visual   fields  were  not  performed  due  to  poor  patient  understanding.  Right-­‐sided  flaccid   paralysis  was  evident  involving  the  lower  face  as  well  as  upper  and  lower   extremities.  A  positive  Babinski  was  present  on  that  side.  He  did  not  respond  to   painful  stimuli  on  the  right  side.  Cardiac  examination  confirmed  tachycardia  with   S1,  S2  present.  A  grade  I  mid-­‐systolic  murmur  was  apparent  in  the  aortic  region.   There  was  no  peripheral  edema  with  adequate  perfusion  at  the  extremities.  A  dorsal   pedis  pulse  was  present  bilaterally.  Breath  sounds  were  equal  and  clear  to   auscultation  without  evidence  of  pulmonary  congestion.  Abdomen  was  soft,  non-­‐ distended,  and  non-­‐tender.  Bowel  sounds  were  present.     Laboratory  Investigations:     Initial  non-­‐contrast  CT  imaging  revealed  a  left  frontal-­‐parietal  embolic/ischemic   non-­‐hemorrhagic  CVA.  Carotid  doppler  studies  revealed  80-­‐99%  occlusion  of  the   right  ICA  and  complete  100%  occlusion  of  the  left  ICA.  Cardiac  echo  showed  mild   generalized  valvular  disease  with  slight  left  ventricular  and  atrial  hypertrophy.   Repeat  CT  imaging  at  24  hours  showed  no  hemorrhagic  conversion  but  with   progression  of  infarction.  CBC,  BMP,  and  lipid  profile  revealed  mild  metabolic   acidosis  (HCO3  19)  and  elevated  blood  glucose  (202).  HDL  and  LDL  were  within   high-­‐risk  therapeutic  target  range  at  53  (>40)  and  65  (<70)  respectively.  
• 2.
  Discussion/Assessment/Plan:     Considering  Mr.  H.B.’s  one-­‐day  prior  history  suggesting  a  transient  ischemic  event   with  similar  manifestations  of  aphasia  and  right  hemi-­‐paresis,  a  diagnosis  consistent   with  subacute  but  progressive  CVA  is  reasonable.  Understanding  the  subacute   nature  of  the  insult,  as  well  as  repeat  CT  showing  infarct  progression,  thrombolytic   tPA  was  likely  futile  performed  outside  the  therapeutic  window  (<3  hours).     It  is  interesting  to  note  doppler  imaging  revealed  100%  stenosis  of  the  left  ICA   confirming  no  blood  flow,  therefore,  cerebral  circulation  has  been  maintained  via   the  right  ICA  despite  the  presence  of  80-­‐99%  occlusion.  With  this  in  mind,  the  area   of  embolic  infarction  involves  the  left  frontal-­‐parietal  region  perfused  via  the  left   middle  cerebral  artery.  Therefore,  this  case  may  represent  a  “trans-­‐hemispheric”   embolic  event  arising  from  the  right  ICA,  crossing  over  via  the  Circle-­‐of-­‐Willis,   subsequently  creating  embolic  obstruction  of  the  left  MCA  or  its  branches.     Assessment:     1. Progressive  left  frontal-­‐parietal  embolic  CVA  likely  secondary  to  carotid   disease.     Plan:     1. Right  carotid  endarterectomy/stenting  not  likely  advisable  due  to  degree  of   stenosis  and  risk  for  intraoperative  or  postoperative  additional  embolic  or   ischemic  events.   2. Continue  monitoring  neurologic  status  –  Mr.  H.B.  was  discharged  to   rehabilitation  center.   3. Continue  treatment  for  hypertension,  diabetes,  and  hyperlipidemia.  Follow-­‐ up  with  neurology  and  primary  care  physician  scheduled.