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

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

Timothy Kleinig

A previously independent, right-handed 68-year-old woman slid to the floor while eating lunch with her husband. She did not lose consciousness, but immediately noticed severe left-sided weakness. She could not get up unassisted, yet kept repeating ‘I’m all right’ to her husband. The ambulance was called and she was taken to hospital. It is now 150 minutes since her collapse.

She has a background history of type II diabetes mellitus, hypertension and dyslipidaemia. She has peripheral vascular disease, but no other micro- or macrovascular complications. Her medications include metformin, gliclazide, perindopril and atorvastatin.

Q.1

What is the most likely cause? What other possibilities should you consider?

You continue your history and examination.

Q.2

What are the important features of the examination and ancillary history?

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 44.3 A CT angiogram.

Q.4

What do the CT and CTA show? It is now 2 hours and 50 minutes post stroke onset. How would you proceed?

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.

Q.5

What in-hospital care should this patient receive and what further investigations should be performed?

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.

Q.6

What are some possible complications which may arise in the subacute stage?

The patient improved over the ensuing week, and was able to mobilize with assistance. Progress was limited by the left-sided ‘neglect’ commonly seen with a non-dominant MCA stroke. She was accepted for ongoing inpatient therapy at a specialized rehabilitation facility.

Q.7

What chronic treatment should this patient receive?

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?

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