Stroke:Case Study Section 2
This case study forms part of the Stroke Course
History of Presenting Condition
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
Asthma - Dx Aged 8
Hypertension Grade 1 - Dx 5 years ago
Prediabetes - Dx 3 years ago
Ventolin (As Required - Not Required for over 1 Year)
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.
- BP 140/90 mmHg
- Pulse 75
- 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)
1. Age greater than 45 years
2. History of Seizures or Epilepsy
3. Onset of Neurological Symptoms is less than 24 hours
4. Patient was Ambulatory prior to onset of symptoms
5. Blood Glucose between 60 and 400 mg/dl
6. Motor Exam: Examine for Motor Asymmetry
Based on Exam below, patient has Unilateral 'Weakness:
|Facial Smile / Grimace||
Acute Hospital Assessment
- BP 145/90 mmHg
- Pulse 82
- 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|
|Visual Field Testing||1||1||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|
|Extinction & Inattention||1||1||1|
- INR 1.2
- 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
- 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 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
Thrombolysis & Endovascular Mechanical Thrombectomy:
- Discussed with Family & Patient
- tPA Prescribed and Initiated within 1hr 54mins After Onset Symptoms
- Endovascualr Thrombectomy Initiated at 3hr
- Admitted to Acute Stroke Unit
- 24 Hour Monitoring
- MDT Referral Received within 24 Hours - OT, SLT & PT