Problem 44 A 68-year-old woman with a left hemiplegia following a conscious collapse

You continue your history and examination.

The patient’s blood pressure is 164/92 mmHg. She is a febrile, alert and in sinus rhythm. Her eyes are conjugate, but deviated to the right. She has a left homonymous hemianopia. Her speech is dysarthric without dysphasia. She has a dense left hemiparesis with only a flicker of movement at the hip. Sensation is absent on the left. She appears to be unaware of her neurological deficit and is trying to get out of bed.

Cardiovascular and general examination is normal.

Q.3

What investigations would you order?

Apart from a blood sugar of 9.6 mmol/L and evidence of left ventricular hypertrophy on ECG, her blood tests and ECG are unremarkable. Other investigations are shown in Figure 44.1–3.

Figure 44.1 Hyperacute CT scan.

Figure 44.2

Figure 44.3 A CT angiogram.

You initiate emergency management, and commence an infusion of thrombolytic as per your stroke unit protocol. After 30 minutes she regains partial power in her left arm and leg, regains sensation to painful stimuli (but not light touch), and she no longer has a conjugate gaze defect.

CTA performed at admission demonstrated only mild atherosclerotic carotid disease. A follow-up CT scan demonstrated a moderate area of infarction within the basal ganglia, and several small cortical areas of infarction (see Figure 44.4), somewhat less than would have been expected from her initial scan. The MCA appeared patent. Transthoracic echocardiography demonstrated an enlarged left atrium, but no thrombus. Fasting blood glucose was 6.2 mmol/L and a HBA1C was 7.8%. Total cholesterol was 5.2, with an LDL of 3.2 mmol/L and HDL of 0.8 mmol/L. While on the ward, 3 days after admission, a rapid and irregular pulse was noted. ECG confirmed atrial fibrillation.

Figure 44.4 Repeat CT 2 days after omission.

You initiate appropriate long-term medical management, counsel the patient and her husband on the risks of recurrence. She does well in rehabilitation, and is able to return to home with assistance from her husband and community supports.

Answers

A.1 It is most likely that this patient has had a stroke. Other causes of a rapidly progressive focal neurological deficit include migraine with aura, epilepsy with a post-ictal Todd’s paresis, a conversion disorder and hypoglycaemia, although the lack of observed ictal activity and the sudden onset of symptoms would make acute stroke the most likely cause. This is an emergency – ‘Time is brain’, and you need to work swiftly in order to provide the best therapy.

A.2 The acute evaluation of a patient with a presumed stroke is guided by the need to determine, as quickly as possible:

• Did she actually have a stroke?

• If so, was it ischaemic or haemorrhagic?

• Does she have any contraindications to thrombolysis?

Other features which are important to establish, but which should not slow a decision regarding the institution of thrombolysis, include:

• What is the severity of the neurological deficit? (This is important to establish a baseline to compare spontaneous or treatment-induced improvement or deterioration.)

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