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<div | <div class="editorbox"> | ||
'''Original Editor '''- [[User:Naomi O'Reilly|Naomi O'Reilly]] | |||
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | |||
</div> | |||
== Introduction == | == Introduction == | ||
Line 101: | Line 106: | ||
5. Blood Glucose between 60 and 400 mg/dl | 5. Blood Glucose between 60 and 400 mg/dl | ||
| | | align="center" | | ||
| align="center" | | Yes | ||
125mg/dl | |||
| align="center" | <br> | |||
| colspan="2" | | | colspan="2" | | ||
|- | |- | ||
Line 150: | Line 159: | ||
|} | |} | ||
== | ==Acute Hospital Assessment== | ||
'''Vitals:''' | '''Vitals:''' | ||
Line 169: | Line 178: | ||
'''Acute Assessment Scale:''' | '''Acute Assessment Scale:''' | ||
'''[https://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf NIH Stroke Scale]: ''' | '''[https://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf NIH Stroke Scale]: '''19 | ||
{| width="100%" border="2" cellpadding="2" cellspacing="2" | {| width="100%" border="2" cellpadding="2" cellspacing="2" | ||
|- | |- | ||
| width=" | | width="40%" | '''Test Elements''' | ||
| align="center" width="20%" | | | align="center" width="20%" | '''On Admission''' | ||
| align="center" width="20%" | '''12 Hours post tPA''' | |||
| align="center" width="20%" nowrap="nowrap" | '''24 Hours post tPA''' | |||
|- | |||
| width="50%" | Level Of Consciousness | |||
| align="center" width="15%" | 1 | |||
| align="center" width="20%" | 0 | |||
| align="center" width="20%" | 0 | |||
|- | |- | ||
| LOC Questions | | LOC Questions | ||
| align="center" | 2 | | align="center" | 2 | ||
| align="center" | 1 | |||
| align="center" | 0 | |||
|- | |- | ||
| LOC Commands | | LOC Commands | ||
| align="center" | 1 | | align="center" | 1 | ||
| align="center" | 1 | |||
| align="center" | 0 | |||
|- | |- | ||
| Best Gaze | | Best Gaze | ||
| align="center" | 1 | |||
| align="center" | 1 | |||
| align="center" | 1 | | align="center" | 1 | ||
|- | |- | ||
| Visual Field Testing | | Visual Field Testing | ||
| align="center" | 1 | |||
| align="center" | 1 | |||
| align="center" | 1 | | align="center" | 1 | ||
|- | |- | ||
| Facial Palsy | | Facial Palsy | ||
| align="center" | 2 | | align="center" | 2 | ||
| align="center" | 2 | |||
| align="center" | 1 | |||
|- | |- | ||
| Motor Function Arm Right | | Motor Function Arm Right | ||
| align="center" | 0 | |||
| align="center" | 0 | |||
| align="center" | 0 | | align="center" | 0 | ||
|- | |- | ||
| Motor Function Arm Left | | Motor Function Arm Left | ||
| align="center" | 4 | | align="center" | 4 | ||
| align="center" | 3 | |||
| align="center" | 2 | |||
|- | |- | ||
| Motor Function Right Leg | | Motor Function Right Leg | ||
| align="center" | 0 | |||
| align="center" | 0 | |||
| align="center" | 0 | | align="center" | 0 | ||
|- | |- | ||
| Motor Function Left Leg | | Motor Function Left Leg | ||
| align="center" | 2 | | align="center" | 2 | ||
| align="center" | 2 | |||
| align="center" | 1 | |||
|- | |- | ||
| Limb Ataxia | | Limb Ataxia | ||
| align="center" | 0 | |||
| align="center" | 0 | |||
| align="center" | 0 | | align="center" | 0 | ||
|- | |- | ||
| Sensory | | Sensory | ||
| align="center" | 1 | |||
| align="center" | 1 | |||
| align="center" | 1 | | align="center" | 1 | ||
|- | |- | ||
| Aphasia | | Aphasia | ||
| align="center" | | | align="center" | 1 | ||
| align="center" | 1 | |||
| align="center" | 0 | |||
|- | |- | ||
| Dysarthria | | Dysarthria | ||
| align="center" | 2 | | align="center" | 2 | ||
| align="center" | 1 | |||
| align="center" | 1 | |||
|- | |- | ||
| Extinction & Inattention | | Extinction & Inattention | ||
| align="center" | 1 | |||
| align="center" | 1 | |||
| align="center" | 1 | | align="center" | 1 | ||
|- | |- | ||
| align="right" | '''Total Score''' | | align="right" | '''Total Score''' | ||
| align="center" bgcolor="#ffff00" | ''' | | align="center" bgcolor="#ffff00" | '''19''' | ||
| align="center" bgcolor="#ffff00" | '''15''' | |||
| align="center" bgcolor="#ffff00" | '''9''' | |||
|} | |} | ||
== Investigations<br> == | == Investigations<br> == | ||
'''Labs:''' | |||
*INR 1.2<br> | |||
'''CT:''' | |||
*Hyperdensity in the M1 Segment of the Right Middle Cerebral Artery, with no other signs suggestive of an Ischemic Stroke noted.<br>Provisional diagnosis of Acute Ischemic Stroke secondary to occlusion of the M1 was made<br>Patient was treated with intravenous Tissue Plasminogen Activator (tPA) at 1 h 54 min after symptom onset | |||
'''MRI:''' | |||
*Multimodal MRI Scan completed at 3 h 09 min after symptom onset demonstrated Ischemic Changes confined predominantly to the Right Middle Cerebral Artery | |||
*Perfusion-weighted MRI showed larger perfusion abnormality, indicating presence of a substantial volume of potentially salvageable penumbral tissue. | |||
*Time-of-flight magnetic resonance angiography showed a loss of signal in the Right Internal Carotid Artery and Middle Cerebral Artery. | |||
'''Cerebral Angiography''' | |||
*Cerebral angiogram performed post MRI demonstrated Occlusive Thrombus extending from the Right Internal Carotid Artery Origin through the Right Middle Cerebral Artery Trunk. | |||
*Recanalization was attempted by Endovascular Thrombectomy performed 4 h 19 min after symptom onset | |||
== Medical Management<br> == | == Medical Management<br> == | ||
'''Thrombolysis & Endovascular Mechanical Thrombectomy:''' | |||
*Discussed with Family & Patient | |||
*tPA Prescribed and Initiated within 1hr 54mins After Onset Symptoms<br> | |||
*Endovascualr Thrombectomy Initiated at 3hr | |||
'''Stroke Unit:''' | |||
*Admitted to Acute Stroke Unit | |||
*24 Hour Monitoring | |||
*MDT Referral Received within 24 Hours - OT, SLT & PT | |||
== Physiotherapy Objective == | == Physiotherapy Objective == | ||
== Physiotherapy Management == | == Physiotherapy Management == | ||
[[Category:Stroke]] | |||
[[Category:Course Pages]] |
Latest revision as of 18:16, 1 March 2022
Original Editor - Naomi O'Reilly
Top Contributors - Naomi O'Reilly, Kim Jackson, Rucha Gadgil and Simisola Ajeyalemi
Introduction[edit | edit source]
This case study forms part of the Stroke Course
History of Presenting Condition
[edit | edit source]
Michael is a 61 year old Senior Partner in a Law Firm. While eating breakfast Michael experienced sudden onset slurring of speech, had facial droop on his left hand side with weakness in left side upper and lower limbs. Michael's wife Mary spotted these sudden onset of symptoms and immediately called for an ambulance, which arrived within 15 mins.
Past Medical History
[edit | edit source]
Asthma - Dx Aged 8
Hypertension Grade 1 - Dx 5 years ago
Prediabetes - Dx 3 years ago
Medication History[edit | edit source]
Seretide Accuhaler
Ventolin (As Required - Not Required for over 1 Year)
Thiazide
Social History[edit | edit source]
61 Year Old Senior Partner at a Law Firm, recently reduced working hours 20 - 30 hours per week, previously worked 50 - 60 Hours
Planning on retirement in 1 - 2 years
Lives in a Bungalow with his wife Mary, who is a recently Retired Teacher.
2 Adult Children, both married with their own children - 1 lives close by, the other lives overseas.
Lifestyle Changes implmented over past 2 - 3 Years foloowing Dx Prediabetes.
Outside work he enjoys golf, usually playing at least 2-3 per week. Also enjoys playing Bridge with Friends.
Took up walking 3 Years ago following Dx Prediabetes. Walks 5 - 6 days per week for between 30 - 45 mins
Ex-Smoker - Hx Smoking 30 Years x 10 - 15/day - Quit 3 Years ago following Dx Prediabetes
Social Beer Drinker 10 - 15 Standard Drinks per week with 3 - 4 per session, although sometimes after Golf may be more.
Pre-Hospital Assessment
[edit | edit source]
Vitals:
- BP 140/90 mmHg
- Pulse 75
Physical Exam:
FAST +ve
- Left Facial Droop
- Left Motor Weakness: Upper Limb 0/5, Lower Limb 2/5
- Slurred Speech
Pre Hospital Assessment Scale:
Los Angeles Prehospital Stroke Screen (LAPSS) & Los Angeles Motor Scale (LAMS)
Criteria | Yes | No | Unknown | |
1. Age greater than 45 years |
Yes | |||
2. History of Seizures or Epilepsy |
No | |||
3. Onset of Neurological Symptoms is less than 24 hours |
Yes | |||
4. Patient was Ambulatory prior to onset of symptoms |
Yes | |||
5. Blood Glucose between 60 and 400 mg/dl |
Yes 125mg/dl |
|||
6. Motor Exam: Examine for Motor Asymmetry Based on Exam below, patient has Unilateral 'Weakness: |
Yes | |||
Equal | Right | Left | LAMS SCORE | |
Facial Smile / Grimace | Droop | 1 | ||
Grip Strength |
|
No Grip |
2 | |
Arm Srength |
|
Falls Rapidly |
2 | |
5 |
Acute Hospital Assessment[edit | edit source]
Vitals:
- BP 145/90 mmHg
- Pulse 82
Physical Exam:
- Confusion
- Left Facial Droop
- Slurred Speech
- Left Motor Weakness Upper Limb 0/5, Lower Limb 2/5
- Decreased Tone
- Altered Sensation
- Mild Left Sided Neglect
Acute Assessment Scale:
NIH Stroke Scale: 19
Test Elements | On Admission | 12 Hours post tPA | 24 Hours post tPA |
Level Of Consciousness | 1 | 0 | 0 |
LOC Questions | 2 | 1 | 0 |
LOC Commands | 1 | 1 | 0 |
Best Gaze | 1 | 1 | 1 |
Visual Field Testing | 1 | 1 | 1 |
Facial Palsy | 2 | 2 | 1 |
Motor Function Arm Right | 0 | 0 | 0 |
Motor Function Arm Left | 4 | 3 | 2 |
Motor Function Right Leg | 0 | 0 | 0 |
Motor Function Left Leg | 2 | 2 | 1 |
Limb Ataxia | 0 | 0 | 0 |
Sensory | 1 | 1 | 1 |
Aphasia | 1 | 1 | 0 |
Dysarthria | 2 | 1 | 1 |
Extinction & Inattention | 1 | 1 | 1 |
Total Score | 19 | 15 | 9 |
Investigations
[edit | edit source]
Labs:
- INR 1.2
CT:
- Hyperdensity in the M1 Segment of the Right Middle Cerebral Artery, with no other signs suggestive of an Ischemic Stroke noted.
Provisional diagnosis of Acute Ischemic Stroke secondary to occlusion of the M1 was made
Patient was treated with intravenous Tissue Plasminogen Activator (tPA) at 1 h 54 min after symptom onset
MRI:
- Multimodal MRI Scan completed at 3 h 09 min after symptom onset demonstrated Ischemic Changes confined predominantly to the Right Middle Cerebral Artery
- Perfusion-weighted MRI showed larger perfusion abnormality, indicating presence of a substantial volume of potentially salvageable penumbral tissue.
- Time-of-flight magnetic resonance angiography showed a loss of signal in the Right Internal Carotid Artery and Middle Cerebral Artery.
Cerebral Angiography
- Cerebral angiogram performed post MRI demonstrated Occlusive Thrombus extending from the Right Internal Carotid Artery Origin through the Right Middle Cerebral Artery Trunk.
- Recanalization was attempted by Endovascular Thrombectomy performed 4 h 19 min after symptom onset
Medical Management
[edit | edit source]
Thrombolysis & Endovascular Mechanical Thrombectomy:
- Discussed with Family & Patient
- tPA Prescribed and Initiated within 1hr 54mins After Onset Symptoms
- Endovascualr Thrombectomy Initiated at 3hr
Stroke Unit:
- Admitted to Acute Stroke Unit
- 24 Hour Monitoring
- MDT Referral Received within 24 Hours - OT, SLT & PT