Stroke Cases

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Stroke Cases

• Adapted from http//www.strokecenter.org
• Revised for March 29, 2006

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Case 1 - Common being common

• 76 y.o. woman
• ED 70 minutes after sudden onset left
  hemiparesis and mildly slurred speech which
  hasn't changed since onset

• Is this a stroke?
• Is this an accute stroke? (i.e. tPA?)
• What else do you want to know?
• What will you look for on exam?

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Case 1 (cont)

• Physical exam
• BP 166/90
• BG 5.7
• L motor weakness
• She can't budge her arm
• She can't budge her leg
• She can't feel her hand or foot
• L plantar extensor response

• What now?
• IV access
• CBC
• Lytes
• Cre/BUN
• PTT/INR
• CT head

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Case 1 (conclusion)

• Would you thrombolyse?
• What medications would you start, if any
• In the acute period
• In the subacute period
• Eventually
• What other investigations would you perform?

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Case 2 - Right from the heart

• 43 y.o. woman
• aortic and mitral valve replacement and had been
  using warfarin
• She stopped it on her own
• ED 120 minutes after sudden onset of left
  hemiparesis involving both the arm and the leg
• INR was normal

• Is this a stroke?
• Is this an accute stroke? (i.e. tPA?)
• What else do you want to know?
• What will you look for on exam?

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Case 3 - Worst case scenario

• 52 y.o man
• Collapsed and lost consciousness while at work
  1.5 hours ago
• No prodrome
• In the ED, he was combative and restless and
  required intubation

• Is this a stroke?
• Is this an accute stroke? (i.e. tPA?)
• What else do you want to know?
• What will you look for on exam?

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Case 3 (conclusion)

• What is the likely etiology of this patient's
  hemorrhage and
• how would you look for it?
• An angiogram was performed, which revealed that
  the patient had a left posterior cerebral artery
  aneurysm, a right internal carotid artery
  bifurcation aneurysm and a basilar tip
  aneurysm. The basilar tip aneurysm was more than
  1 cm in diameter and regular in shape and was
  felt to be most likely to the source of the
  patient's hemorrhage.

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Case 4 - First, do no harm

• 83-year-old man arives at the ED 1 hour 55
  minutes after he slumped over while eating dinner
• He remained alert and awake but his family noted
  that he slumped towards his left side and had
  left arm and leg weakness.
• Atrial fibrillation (no prior history)
• His neurological exam demonstrated left
  hemiparesis involving the arm and leg

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Case 5 - And now for something completely
different

• 34 y.o. woman
• Sudden fall
• Confused and combative
• Unble to provide a history but she had multpile
  bruises and an indurated bruise over her left
  scalp
• She had right hemiparesis on exam

• Is this a stroke?
• Is this an accute stroke? (i.e. tPA?)
• What else do you want to know?
• What will you look for on exam?

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Case 6 - A massive problem

• 62 y.o. man
• Sudden onset aphasia and right-sided weakness
• Px's eyes are forced to the left, and he does not
  respond to visual threat on the left
• He does not feel anything over his right side,
  including his face
• He has florid hyper-reflexia over the right with
  sustained clonus on the right there is mild
  spasticity as well

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Case 6 (conclusion)

• On closer questioning of family members, it
  appeared that his weakness and aphasia may have
  been more chronic and gradually progressive.

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End