stroke case senarios .pptx

stroke case senarios .pptx

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  Stroke cases :Various clinical scenarios Dr . Ahmed Kohail Stroke Program Co-ordinator and Fellow of the European Board of Neurology ( FEBN )
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  Case No.1
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  A female patient30 ys old , known case of migraine with frequent attacks , but not on prophylactic medications . On 19th of September 2016, she was following up with an obstetrician for primary infertility for one year. She had irregular cycles, missed period and normal levels of Luteinizing Hormone (LH), Follicular Stimulating Hormone (FSH) and Thyroid Stimulating Hormone (TSH). Trans-vaginal Sonography (TVS Showed normal ovaries with multiple premature follicles. She was started on metformin and clomiphene sulfate as a case of polycystic ovarian disease. On follow up, TVS showed no dominant follicles Therefore, FSH injections, epigonal, started. After multiple visits no improvement. Case Presentation
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  On 4th of February2017, she was started on norethisterone, primolut-N. Six weeks after that on 15-3-2017, she presented in ED with abdominal pain, nausea, acute increase in body weight, and fatigue. Hemoglobin was 17 and hematocrit was 47. Ultrasonography (US) showed ovarian enlargement with multiple follicles, (33mm) uterine thickness, and marked ascites ( Picture suggestive of ovarian hyperstimulation syndrome ) . She was admitted for intravenous fluid therapy,and abdominal drainage of ascites . Additionally, elastic stockings and low-molecular-weight heparin prophylactic dose were initiated . She was discharged , with a normal hematocrit, on thromboembolic stockings and prophylactic dose of low molecular weight heparin . Case Presentation
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  One week later, she presented to ED with acute left sided weakness 36 hrs ago , upper limb is more affected than lower limb, hypotonia, deviation of angle of the mouth to the right side, and dysarthria. There were no seizures, trauma, Disturbed conscious level, or fever. At that time her neurological examination revealed , fully conscious state , dysarthria , Lt side weakness , UL ( power grade 3 ) > LL ( power grade 4) , D > P , with hypotonia , hyporeflexia and plantar reflex was extensor in the left side . National Institutes of Health Stroke Scale (NIHSS) was 6 Case Presentation
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  At that time, MRI brain , MRV , and MRA intracranial vessels were done which showed Right basal ganglion and peri insular area of restricted diffusion together with occlusion of the right MCA after the M1 segment ,while MRV was unremarkable .The patient was out of window of either thrombolytic therapy or mechanical thrombectomy . Moreover, pregnancy test was positive, hemoglobin was 18 and hematocrit was 48 , +3 proteins and +2 blood in urine. Her collagen profile and thrombophilia screen were unremarkable . Case Presentation
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  Case Presentation
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  Case Presentation She wasadmitted as a case of acute ischemic stroke as a complication of ovarian hyperstimulation syndrome and was treated accordingly , and she was commenced on low-molecular-weight heparin for the remainder of her pregnancy. The patient improved neurologically through the rest of her pregnancy, with normal fetal growth parameters and structural scans for fetal anomalies. She eventually delivered a healthy normally grown baby boy at 39 weeks’ gestation by elective cesarean delivery. At the time of delivery, she had a power grade 5/5 of her left lower limb, and had grade 4/5 power in her left upper limb.
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  Case No.2
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  Case Presentation A 15years old female with history of Sickel Cell Disease (SCD) hemoglobin SS (HbSS) genotype since birth with recurrent sickle cell crises and exchange transfusion. The patient was presented to Emergency Department (ED) with a 3-day history of severe headache, impaired concentration and pain in her legs and arms. The patient experienced worsening of headache and concentration over that 3-days despite pain killers ( Paracetamol 1 gm three times daily since symptoms started) and then developed recurrent attacks of generalized convulsions followed by disturbed conscious level state and left sided weakness 2 hours before presentation to ED.
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  Case Presentation General examination:GCS: 10/15, Vital signs: ( Heart Rate: 112 beat/minute , Respiratory Rate: 21 breaths/minute, Temperature: 37.3 C, Blood Pressure 145/90 mmHg, Oxygen saturation: 95% on room air). Pale complexion , yellowish discoloration of sclera in both eyes, under weight (Body Mass Index 17 ), Myalgia different sites of the body, Palpable enlarged spleen, other general examination was unremarkable. Neurological examination: Dysphasia, conjugate eye deviation to the right side ,left sided weakness lower limb power grade 3 and upper limb power grade 4 , weakness was distal more than proximal , left sided hypotonia lower limb more than upper limb , reflexes were brisk in left side , left extensor plantar response, neurological examination of the right side was unremarkable , and other neurological tests including sensory examination and tests of coordination could not be assessed accurately at time of examination due to impairment of conscious level.
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  Case Presentation The patientdeveloped another witnessed generalized tonic clonic seizure while being transferred to Brain Imaging Room. Status Epilepticus protocol was started and 0.3 mg/kg midazolam given intravenous, followed by loading phenytoin 20 mg/kg and seizure was aborted and the patient had Computed Tomography (CT) Scan without contrast and revealed bilateral frontal cortical and subcortical hypodense ischemic lesion mainly involving anterior and parafalcine regions in addition to minimal hyperdense smearing of subarachnoid spaces in right anterior frontal parasagittal and bilateral high frontal cortical sulci. Significant laboratory results: LDH 437 U/L, Creatinine 1.9 mg/dl, Total Bilirubin 4.0 mg/dl, Direct Bilirubin 0.9 mg/dl, Ncov-2019 PCR swab test Negative, INR 1.3, Hb 8.9 g/d, Reticulocyte 7.28%, Hb S was 39% of total Hb.
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  Case Presentation Computed TomographyAngiography (CTA) was recommended and discussed with parents benefit/risk ratio but they refused at time of admission or even doing digital subtraction angiography (DSA) due to possible risk of renal failure. The patient was then admitted in Intensive Care Unit (ICU) and hematologists recommended for exchange transfusion as she was in crisis and repeated till Hb S become less than 30% of total Hb. The patient was given nimodipine 60 mg every 4 hours through Nasogastric Tube (NGT) with monitoring of blood pressure plus phenytoin 100mg intravenous twice daily, intravenous fluids, in addition to physiotherapy and intermittent pneumatic compression for venous-thrombo- embolism prophylaxis.
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  Case Presentation The patientregain fully conscious after 1 day , mild dysarthria, left sided weakness the same grade at time of admission , sensory examination intact , no seizure recurrence. By the second day kidney function tests improved and serum creatinine become 1.2 mg/dl and parents accept to do CTA which revealed Saccular aneurysm at junction of anterior communicating artery with A1 segment of left anterior cerebral artery, Marked attenuated right internal carotid artery (extra and intracranial parts) and both anterior cerebral arteries mainly right one denoting vasospasm.
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  Case Presentation Parents refusedDSA after discussion between parents , hematologist, Neurovascular Interventionlist, and Neurologist. The patient showed significant improvement in the next days regarding hemodynamics , seizure control , left sided weakness which become full power in left upper limb and grade 4 in left lower limb , speech become intact regarding articulation , comprehension, repetition . Sickle cell crisis subsided after 4 sessions of exchange transfusion and Hb S become less than 30% of total Hb , Jaundice subsided, pallor improved Hb become 10.4 g/d CT brain without contrast follow up revealed significant regressive course of subarachnoid hemorrhage and frontal lobe ischemia. The patient was then discharged home after 10 days and appointed for follow up at neurology and hematology outpatient clinic with a plan for rehabilitation.
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  Case No.3
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  Case Presentation Female patient,77 year old , past history of Hypertension, Diabetes Mellitus, Ischemic Heart Disease. The patient was presented to Emergency Department (ED) complaining of sudden onset and stationary course of right sided weakness, impaired speech articulation ,comprehension and repetition 2 hours and 30 minutes before presentation to ED. On Examination: The patient was sleepy , GCS 10/15 , Temperature:37.1 C, Blood Pressure 150/95 mmHg, Respiratory Rate 19 breaths/minute, Heart Rate 98 beat/minute, Random Blood Sugar 230 mg/dl, Oxygen saturation 96% on room air. Code Stroke in the hospital was activated in 4 minutes of the patient arrival to ED. General examination of body systems other than Central Nervous System (CNS) was unremarkable. Neurological examination: Global aphasia, right upper motor neuron facial paralysis , conjugate deviation of both eyes to the left side (Right Gaze Palsy). Right hemiparesis ( upper limb more than lower limb , distal more than proximal ) power grade in upper limb was 1 and lower limb was 3. Right sided hypotonia . Right sided hypo-reflexia .
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  Case Presentation Right extensorplantar response Neurological examination to the left side was unremarkable Sensory examination and tests of coordination could not be assessed at that time due to impaired conscious level. National Institutes of Health Stroke Scale (NIHSS) was 18 Two wide bore intravenous (IV) access were placed , nasal oxygen 3 liter/minute was placed after drop of oxygen saturation below 94%. The patient was urgently sent to Computed Tomography (CT) room and the door to CT time was 15 minutes. CT Brain without contrast was done and revealed early ischemic changes in left temporal lobe (Basal Ganglia, Insula)
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  Case Presentation Alberta StrokeProgram Early CT Score (ASPECTS) score was 7 and door to CT interpretation was 25 minutes. Laboratory investigation: INR 1.1 other routine labs were unremarkable The patient was revised regarding inclusion and exclusion criteria to receive IV recombinant tissue plasminogen activator (rtPA) and she met it , discussion was done was the patient first degree relatives about benefit/risks of receiving IV rtPA and written consent was obtained and rtPA (Brand Name: Actilyse) was rapidly prepared after calculation of total dose at 0.9 mg/kg and bolus (10% of total dose ) was iv given and the rest was given IV over 60 minutes and the door to needle time was 38 minutes and the onset to treatment time was 3 hours and 8 minutes.
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  Case Presentation The patienthad Computed Tomography Angiography (CTA) while she is on IV rtPA infusion and showed left carotid bulb calcified atheromatous plaques with luminal stenosis 55% and distal extension of mural thrombus in internal carotid artery (ICA) with distal progressive narrowing up to total occlusion of distal bifurcation and middle cerebral artery (MCA). The patient was candidate to Mechanical Thrombectomy and door to groin puncture was 70 minutes and IV rtPA was still infused till time of groin puncture and then was holded. The MCA clot was removed using stent retriever device (Solitaire Platinum 6x40 mm, Medtronic). Successful recanalization of both left ICA and MCA was achieved as shown in the following images.
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  Case Presentation
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  Case Presentation After successfulrecanalization the patient was re-evaluated and become fully conscious , mild dysarthria, mild right upper motor neuron facial paralysis , the right hemiparesis improved from severe weakness to mild weakness in right upper limb power grade 4 and right lower limb power grade 5. NIHSS was 4 The patient was then transferred to stroke Intensive Care Unit (ICU) to complete the plan of management with tight control of vital signs and careful monitoring of both general and neurological condition. The patient completed her stroke work up which was unremarkable except hyperlipidemia Low Density Lipoprotein (LDL) was 221 mg/dl, also early physiotherapy was started and CT brain without contrast follow up after 24 hours was done and revealed acute left basal ganglia infarction with no hemorrhagic transformation, consequently anti-ischemic preventive measures were started . After improvement of the patient condition she was discharged to stroke ward and then to home after 5 days of hospital admission and her Modified Rankin Scale (mRS) that monitor post-stroke disability was1. The patient was appointed to follow up in stroke preventive clinic and rehabilitation program.
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  Thank You