Problem 44 A 68-year-old woman with a left hemiplegia following a conscious collapse
You continue your history and examination.
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.
Q.4
What do the CT and CTA show? It is now 2 hours and 50 minutes post stroke onset. How would you proceed?
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.
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.
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.
