CASE REPORT

CEREBRAL THROMBOSIS

Mei Risanti Sirait, S. Ked (04104705362)

Preceptor : dr. H. A. Rachman Toyo, SpS(K)

NEUROLOGY MEDICAL RECORD

IDENTIFICATION
: Mr. A : 50 years : Male : Jl. Srijaya Lorong Bersama No 1056, Alang-alang Lebar Religion : Moslem Admission date: May 21st, 2012 Name Age Sex Address

ANAMNESIS
The patient was admitted to Neurology department of Moh Husein General Hospital because of the weakness on his right arm and lower limb which happened suddenly.

 21 hours before admission to the hospital, while resting, suddenly he felt weakness on his right arm and lower limb without decrease of consciousness. At that time, he didnt experience headache, nausea and vomit, stiffness or disturbance of sensibility on the right side. The weakness between his right arm and lower limb was similiar degree.

The patient is right handed. He could express by speech, hand writing and geasture. The patient understood other peoples mind which was expressed by talking, writing and giving sign. When he talked, his mouth deviate and experience slurred speech. He had no complain about urination and defecation.

There are no previous history of headache in the morning, history of getting painless lession and self healing in the eksternal genital and his wife has no history of abortion in > 16 weeks. There's no history of hypertension and diabetes mellitus. This illness was the first time for him.

PHYSICAL EXAMINATION
Internal State Sense

: compos mentis (E4M6V5) Nutrition : adequate Pulse : 86 beats/min Respiratory rate: 20 times/min Blood pressure : 180/100 mmHg Temperature : 37,20C

Weight Height Lungs Liver Spleen Extremities Genital

: 70 kg : 172 cm (BMI: 23,61) : no abnormality : no abnormality : no abnormality : see neurological state : no abnormality

Neurological state
N. I N. II : anosmia (-), parosmia (-) : anopsia (-), hemianopsia (-), edema papil (-), papil atrophy (-), retina bleeding (-) N. III, IV and VI: pupil round, 3mm isochor, light reflex (+/+)

OD

OS

 N. V

: corneal reflex (+), bitting (+), normal, no sensory deficit in trigeminal area N. VII : right nasolabial fold slightly flat, asymetric facial shape N. VIII : no abnormality N. IX and X: pharyngeal arc are symmetrical, uvula located in central, no disturbance of swallowing and normal voice

 N. XI N. XII

: no weakness in lifting shoulder and turning head around : deviation to the right, no atrophy papill, fasiculation and dysarthria

Motoric Function
Right Arm Motion Strenght Tone Insufficient 4 Left Arm Sufficient 5 N Right Limb Insufficient 4 Left Limb Sufficient 5 N
N

Clone
Physiological Reflex

Pathological
Refllex

+ (B)

Other Neurologic Function

Sensory Function Vegetatif Function Higher cortical function Meningeal sign Abnormal movement Gait and postural : no abnormality : no abnormality : no abnormality :::-

Laboratory Finding
BLOOD (May 23rd, 2012) Hb : 14,9 g/dl Ht : 44 Leukocyte : 7300/mm3 Trombocyte : 226.000 DC : 0 / 3 / 1 / 62 / 22 / 10 BSS : 113 mg/dl HDL : 35 mg/dl LDL : 146 mg/dl Trigliseride : 103 mg/dl Uric Acid : 5,3 mg/dl Ureum : 19 mg/dl Creatinine : 1,1 mg/dl

( 14 18 ) ( 40 - 48 ) ( 5000 - 10.000 ) ( 200.000 500.000 )

( < 55 ) ( < 130 ) ( < 150 ) ( 3,5 7,1 ) ( 15 39 ) ( 0,9 1,3 )

Spesific Examination
1. Chest X-Ray : normal chest 2. Brain CT-Scan : Infarct ischemic in left radiate corona.

 Slight hypodense lession with uncertainty border in left corona radiata Sulci, fissura of sylvii and gyrii in good condition Gray and white matter differentiation are clear No deviation on midline Infrateritorial: pons, cerebellum are in good condition Ventricles and cysternae system is not narrow, magna cysternae is prominent Air cell pneumatitation for right and left mastoid is good Occuli bulbi and left and right retroorbita area are good

Diagnosis
A. Clinical Diagnosis : 1. Right hemiparesis spastic type 2. Right VII nerve palsy centre type 3. Right XII nerve palsy centre type B. Topical Diagnosis : Left interne capsule hemisphere C. Etiological Diagnosis : Cerebral thrombosis DD: 1. Cerebral hemorrhage 2. Cerebral emboli 3. Cerebral thrombosis

Management
Bed rest low salt semi solid diet IVFD RL gtt xxx/M citicholine 2x250 mg IV aspilet 1x80 mg tab Vitamine of B1,B6,B12 3x1 tab

Prognosis
Quo ad vitam Quo ad functionam : bonam : dubia ad bonam

THANK YOU

Case Analysis

Topic Diagnosis

1. Lession in left cerebral cortex hemisphere

Lession in left cerebral The symtomps found in the

cortex hemisphere, the symtomps: patient:

Motoric

deficit

(right Right hemiparesis spastic type No seizures on the paralysed side

hemiparesis)

Iritative symtomps (seizure The paralysis of right arms and on the right side) right lower limb are similiar (The No sensibility disorder on the right side body the

Focal

symtomps

paralysis is not similiar )

Sensoric

deficit

on

paralysed side

2. Lession in left cerebral subcortex hemisphere

Lession cerebral in left The symtomps found in the subcortex patient:

hemisphere,
symtomps

the

Motoric

deficit Right hemiparesis spastic

(hemiparese
dextra)

type
No pure motoric aphasia

Motoric aphasia

3. Lession in left interne capsule hemisphere

Lession in left interne capsule hemisphere, the symtomps: Hemiparesis/hemiplegi typica Right VII nerve palsy The symtomps found in the patient: Right hemiparesis spastic type Right VII nerve palsy centre

centre -

type
Right type The weakness in the paralysed side is similiar XII nerve palsy centre -

type
Right XII nerve palsy centre type The weakness in the paralysed side is similiar

The possibility of lession in left interne capsule hemisphere can be made as topic diagnosis .

Etiological Diagnosis

Siriraj Stroke Score

(2,5 x level of consciousness) + ( 2 x Vomity) + ( 2 x Headache) + (0,1 x diastolic blood pressure) (3 x atheroma marker) 12 : (2,5 x 0 ) + ( 2 x 0) + (2 x 0) + (0,1 x 90) (3 x 0) 12 : 0 + 0 + 0 + 9 0 12 :-3 Conclusion : Non cerebral haemorrhagic

1. Cerebral haemorrhagic The symtomps: The symtomps found in the patient: - Unconciusness > 30 minutes - Contralateral centre Hemiparesis None None

2.

Cerebral emboli The symtomps found in the

The symtomps:

patient:
- Unconsciousness < 30 minutes - Arterial fibrillation None None

3. Cerebral thrombosis

Thrombosis cerebri, the

symtomps:

The symtomps found in the

patient:

-Without unconsciousness
-- Happen in resting time

- Without unconsciousness
- Happen in resting time

Aterosklerosis

THERAPEUTIC WINDOW JENDELA PENGOBATAN 0 -4- 6 hr : POTENTIAL FULL RECOVERY 6 12 hr : POTENSTIAL PARTIAL RECOVERY

12 24 hr : POSSIBLE RECOVERY
24 36 hr : START OF INFARCTION

Repairing depends on
Type of stroke Extent of ischaemic Collateral system Immediate therapy It was first attack Power of right arm and limb is 4 There is no unconscioussnes