Neurology: case reviews – CVS – Flashcards
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Case1 Where is the lesions? 1. left arm/leg weakness, left facial droop, slurred speech, running into things on the left and "confusion" 2. Past history of hypertension and dyslipidaemia, plus family history of stroke. On exam, no focal neurological signs but BP 160/90 3. what investigation are needed and why?
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- right hemisphere, likely involving: - right motor cortex or underlying tracts - right parietal or temporal cortex and underlying Confusion- neglect optic radiation - above = right MCA territory - why not: - right ACA or PCA territory? - right internal capsule? - right brain stem? Investigation - (CT brain) - mainly for older strokes - U/S carotids - the pivotal test - ECG - AF, LVH - Holter if episodes of palpitations on history - echo if cardiac history, abnormal ECG - fasting glucose and lipids
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Case 1 Given the results - CT brain - some periventricular hypodensity - ECG: SR, LVH - echo: LVH, normal LA size, normal LV function - BP 160/90 what management?
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> all above imply significant H/T > ACEI - fasting glucose 5.7 = IFG > diabetic diet - chol 6.5, LDL 3.4, HDL 1.0, TG 2.3 > statin - anteplatelets - dipydamole vs aspirin - U/S carotids: right ICA stenosis 70% > carotid endartarectomy, within two weeks
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Case 2 70 year old woman presents at 1600 after being found on floor at 1515 by husband, not speaking, not moving right arm or leg and with right facial droop. In AF (not known previously). BP 175/95. On exam, dense right hemiparesis (including right UMN facial palsy), right hemianopia and global dysphasia 1. where is the lesion?
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Cortical vs white matter lesion - left hemisphere, involving: - left motor cortex - left temporal and frontal speech areas - left optic radiation - all above are left MCA territory
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Case 2 70 year old woman presents at 1600 after being found on floor at 1515 by husband, not speaking, not moving right arm or leg and with right facial droop. In AF (not known previously). BP 175/95. On exam, dense right hemiparesis (including right UMN facial palsy), right hemianopia and global dysphasia Pathogenesis?
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- left MCA territory ischaemic stroke - left hemisphere haemorrhage - multi- causes other causes: tumour bleeding.
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Case 2 70 year old woman presents at 1600 after being found on floor at 1515 by husband, not speaking, not moving right arm or leg and with right facial droop. In AF (not known previously). BP 175/95. On exam, dense right hemiparesis (including right UMN facial palsy), right hemianopia and global dysphasia Investigations?
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urgent CT brain with perfusion and angiography - CT scan - rule out hemorrhage. urgent FBC, Coags, BSL
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70 year old woman presents at 1600 after being found on floor at 1515 by husband, not speaking, not moving right arm or leg and with right facial droop. In AF (not known previously). BP 175/95. On exam, dense right hemiparesis (including right UMN facial palsy), right hemianopia and global dysphasia Management?
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thrombolysis with alteplase if: - can confirm onset within 4.5 hours (ask when was he last seen normal?) - NIH stroke score 4-22 - can get BP < 185/110 - no major surgery in last 2 weeks - Coags and platelets normal - etc. thrombolysis with alteplase nil orally aspirin (delayed if thrombolysis) later anticoagulation given AF - why later?- consolidation of clot to prevent bleeding. aim BP < 185/110 initially and < 130/80 eventually (bring down gradually) aim LDL < 2.3 aim fasting glucose < 5.5 or HbAac < 7%
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Case 3 69 year old retired teacher presents one hour after sudden onset of right arm and leg weakness with right facial droop and slurred speech. BP 200/110. 1. where is lesion?
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- anywhere from right motor cortex to right brain stem (right corticospinal tract originates from right motor cortex, traverses internal capsule and descends right side of brain stem until decussates at lower medulla)
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Case 3 69 year old retired teacher presents one hour after sudden onset of right arm and leg weakness with right facial droop and slurred speech. BP 200/110. 2. pathogenesis 3. Tests
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- infarct - haemorrhage - many causes, commonest are hypertension and cerebral amyloid angiopathy Investigations - CT scan - hypodensity - hemorrhage
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Case 3 69 year old retired teacher presents one hour after sudden onset of right arm and leg weakness with right facial droop and slurred speech. BP 200/110. Site?
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= right internal capsule /basal ganglia hypertensive haemorrhage
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Case 3 69 year old retired teacher presents one hour after sudden onset of right arm and leg weakness with right facial droop and slurred speech. BP 200/110. Mangement?
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- aim less than BP 140-160 initially / < 130 eventually - cease aspirin, avoid thrombolysis! - nil orally - ICH score (out of 6) predicts 30 day mortality GCS 3-4 (+2) 5-12 (+1) 13-14 (0) volume ≥ 30 (+1) < 30 (0) intraventricular? Y (+1) N (0) site? infratentorial (+1) supratentorial (0) age ≥ 80 (+1) <80 (0) eg., score of 2 (26%), 3 (72%), 4 (97%)
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Case 4 30 year old waitress presents with sudden onset of visual loss, which she feels involves the left eye. The symptoms followed neck manipulation by her chiropractor, who she was seeing for neck pain. No other symptoms, other than ongoing neck pain and vague occipital headache. Past history of migraine, smoking and is on the oral contraceptive pill. a) What might you find on visual examination?
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- assess whether eye or field - if eye, monocular acuity loss and often abnormal fundus - if field, hemianopia or quadrantanopia implies cerebral issue involving optic radiation or visual cortex - given history, field loss more likely
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Case 4 30 year old waitress presents with sudden onset of visual loss, which she feels involves the left eye. The symptoms followed neck manipulation by her chiropractor, who she was seeing for neck pain. No other symptoms, other than ongoing neck pain and vague occipital headache. Past history of migraine, smoking and is on the oral contraceptive pill. b) On exam, note left hemianopia - where is lesion?
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- right optic radiation or right occipital cortex
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Case 4 30 year old waitress presents with sudden onset of visual loss, which she feels involves the left eye. The symptoms followed neck manipulation by her chiropractor, who she was seeing for neck pain. No other symptoms, other than ongoing neck pain and vague occipital headache. Past history of migraine, smoking and is on the oral contraceptive pill. c) What might cause this (ie, aetiology)?
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- given sudden onset and neck pain: ischaemic stroke via vertebral or carotid dissection - other causes of stroke in young: - migraine (especially smokers on the OCP) - hypercoagulable disorder - cerebral venous thrombosis - cardiac anomaly
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Case 4 30 year old waitress presents with sudden onset of visual loss, which she feels involves the left eye. The symptoms followed neck manipulation by her chiropractor, who she was seeing for neck pain. No other symptoms, other than ongoing neck pain and vague occipital headache. Past history of migraine, smoking and is on the oral contraceptive pill. Tests?
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- initial CT, later MRI to clarify - U/S carotids or CTA neck/brain??? - hypercoagulable factors - echo
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Case 4 30 year old waitress presents with sudden onset of visual loss, which she feels involves the left eye. The symptoms followed neck manipulation by her chiropractor, who she was seeing for neck pain. No other symptoms, other than ongoing neck pain and vague occipital headache. Past history of migraine, smoking and is on the oral contraceptive pill. Management?
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- for dissection, awaiting trial data to clarify antiplatelet vs antithrombotic treatment - otherwise, management similar to acute ischaemic stroke
