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GROUP VIII:

LIM, ADRIAN MICHAEL


MACAWILI, MADEL
MARTILLANA, WYNDSOR
PAGDANGANAN, NOAH ANGELA
SILLA, EARICA
TRISTEZA, NIKKI
TUQUERO, FRANCES OWEN
CASE
DISCUSSION
 A. J., 54 year-old/ Male
 Right-handed

 With 2 children

 Roman Catholic

 From Tondo, Manila

 Admitted to hospital on Dec.

27, 2006
 RIGHT ARM AND LEG
NUMBNESS
 Patient was of GOOD FUNCTIONAL
CAPACITY

Until 5 days prior to admission:


 He suddenly felt NUMBNESS on his

RIGHT UPPER ARM and LEG


 While driving, he noted PROGRESSION

of NUMBNESS

Developed WEAKNESS
on his RIGHT HAND and
LEG

He was immediately
brought to E.R.
 Ambulatory with difficulty
 1st BP = 180/100

*Given Clonidine 0.75mcg


(sublingual)
 2nd BP = 140/90

 Cholesterol = Elevated

 Triglyceride = Elevated
 RBS = Elevated
 CBC = Normal

 BUN-CREA = Normal

 CT = Unremarkable

 Admitted for Observation (12hrs)

- requested to go home as his


weakness disappeared
 Developed HEADACHE
 SLURRING of SPEECH

 RIGHT ARM and LEG

WEAKNESS
 (+) Headache  (-) Weight Loss
 (-) Blurring of Vision  (-) loss of
 (-) Loss of Balance
Appetite
 (-) Incontinence
 (-) Fever
 (-) Difficulty in
 (-) Bowel
Swallowing
Disturbances
 (-) Heart Disease
 (-) Previous Surgeries

 (-) Known Allergies

FAMILY MEDICAL HISTORY


 (+) Stroke – Father
 (+) Hypertension – Maternal Relatives

 (+) Diabetes - Maternal Relatives


 Smoker – 1 pack/day x
50 years
 Heavy Alcoholic

Beverages Drinker
 Prefers to eat MEAT and

SALTY FOOD
 Awake
 Stretcher-Borne

 Not in Cardiorespiratory Distress

 BP = 160/100

 HR = 80-90(Irregular)

 RR = 30

 T = afebrile
 Pink Conjunctivae, Anicteric Sclerae
 No Cervical Lymphadenopathies

 Equal Chest Expansion, Clear Breath sounds,

No Crackles
 Distinct Heart sounds, irregular rate and

rhythm, No Murmurs
 Abdomen flat, Soft, Non-tender, No Palpable

Masses
 Pink Nailbeds, full pulses, No Edema
 Awake
 UNCOOPERATIVE

 NO VERBAL OUTPUT

 UNABLE to FOLLOW

COMMAND
 CN II - Distinct Disc Borders
- NO Hemorrhages on Fundoscopy
 CN III - Pupils 3mm equal
- Briskly Reactive to Light
 CN III, IV and VI – Preferential Gaze to
the LEFT
- NO Response to Visual threat on the
RIGHT
 CN V and VII – Sluggish Corneal on the
RIGHT
 CN VII - Shallow Right Nasolabial Fold

- Symmetric Forehead Wrinkling


 CN IX – Can Swallow and GOOD GAG

 CN XII – Tongue deviated to the RIGHT


 Withdraws LEFT EXTREMITIES to
PAIN
 NO Withdrawal on the RIGHT

EXTREMITIES

SENSORY:
 NO RESPONSE on the RIGHT on
PAINFUL STIMULATION
+++ ++

+++ ++

+++ ++
+++ ++
 (+) Babinski, R
 Cerebellars : No Nystagmus

 Autonomics : (+) Incontinence

 Meningeals : Supple Neck


 A. J., 54 year-old/ Male
 Right-handed

 Admitted to hospital on

Dec. 27, 2006


 RIGHT ARM AND LEG

NUMBNESS
 In GOOD FUNCTIONAL CAPACITY

Until 5 days prior to admission:


 FEEL NUMBNESS on his RIGHT

UPPER ARM and LEG


*Noted PROGRESSION of
NUMBNESS
 Developed WEAKNESS on his

RIGHT HAND and LEG


 Increase Blood Pressure
1st BP = 180/100
2nd BP = 140/90

Increase LIPID PROFILE & RBS


Ambulatory with difficulty
 Developed HEADACHE
 SLURRING of SPEECH
 RIGHT ARM and LEG WEAKNESS

 (+) Stroke – Father


 (+) Hypertension – Maternal

Relatives
 (+) Diabetes - Maternal Relatives
Smoker – 1 pack/day x 50 years
Heavy Alcoholic Beverages Drinker

Prefers to eat MEAT and SALTY FOOD


Awake, Stretcher-Borne
BP = 160/100 ; HR = 80-

90(Irregular)
RR = 30

Other P.E. = Unremarkable


UNCOOPERATIVE
NO VERBAL OUTPUT

UNABLE to FOLLOW COMMAND


 NO Withdrawal on the RIGHT
EXTREMITIES
 NO RESPONSE on the RIGHT on PAINFUL

STIMULATION
 CN III, IV & VI - Preferential Gaze to LEFT
- NO Response to Visual threat on the
RIGHT
 CN V and VII – Sluggish Corneal on the
RIGHT
 CN XII – Tongue deviated to the RIGHT
(+) Babinski, R
Cerebellars : No Nystagmus

Autonomics : (+) Incontinence

Meningeals : Supple Neck


UPPER MOTOR LOWER MOTOR
NEURON NEURON LESION
LESION

Babinski Flaccid
Sign paralysis
Severe Atrophy of

paralysis muscles
(-) Muscle Muscular

atrophy fasciculation
Spasticity Muscular
 In hemorrhagic stroke, bleeding in the brain itself
(intracerebral hemorrhage) or between the brain and the
skull (subarachnoid hemorrhage) disrupts brain function
 Bleeding usually occurs because of a rupture in arterial walls
that are already weakened by high blood pressure.
 A pool of blood compresses brain tissue in its vicinity,
preventing adequate amounts of fresh blood from reaching
the area.
RULED IN: RULED OUT:
 Severe headache  Nausea
 Chronic high blood
 Vomiting

pressure  Seizures
 Weakness, loss of
 Vision may
sensation, and
numbness, be impaired
 Unable to speak or or lost
become confused
RULED IN: RULED OUT:
 Amaurosis fugax - or transient
 Neurologic Signs monocular blindness, occurs
and Symptoms from emboli to the central
retinal artery of one eye
(Motor and  Disappears within 24 hours

Sensory Deficits)
RULED IN:
 Occurred at rest
 Diabetes, Hypertension, Smoking

 Absence of pain

*However, pain is not uniformly present in


patients with STEMI. The proportion of
painless STEMIs is greater in patients with
diabetes mellitus, and it increases with age
 Confusional State (?)
 Sensation of Profound

Weakness
 Evidence of Peripheral

Embolism (?)
 Arrhythmia (PE
 Chest pain (heavy, squeezing,
crushing)
 Syncope

 DROP IN ARTERIAL PRESSURE

 Evidence of Peripheral Embolism (?)

 Presence of a murmur
 Severe headache with exertion
 Sudden onset headache

 Focal neurologic deficits – caused by

mass effect of subarachnoid


hemorrhage after aneurysmal rupture
 Hemiparesis

 Aphasia

 Abulia – an absence of willpower or an

inability to act decisively


 Increased ICP
 Sudden Loss of Consciousness then

massive headache
 Massive headache then Loss of

Consciousness
 With neck stiffness

 CT findings (CT angiography can find

aneurysm easily)
 Watershed Infarcts present (Visible in

CT)
RULED IN: RULED OUT:
(-) Trauma --- ?
 Hemaparesi S/Sx gradually develops

s over a peroid of days or


 Headache weeks
 Aphasia and hemi-

anesthesia - not present


in subdural hematoma.
 Headache
 Focal Neurologic Signs

 Altered Consciousness

 No Nuchal Rigidity
 Seizures
Fever

With Nuchal

Rigidity
 Causes include myocardial infarction, cardiac arrest,
shock, asphyxiation, paralysis of respiration, and
carbon monoxide or cyanide poisoning. In some
circumstances, hypoxia may predominate. Carbon
monoxide and cyanide poisoning are termed
histotoxic hypoxia since they cause a direct
impairment of the respiratory chain.
 Tachycardia
 Tachypnea

 Proximal Weakness 

Proximal Paralysis
 Loss of Consciousness within Seconds
 Memory Deficit

 Specific Form (Watershed Infarcts) –

- Distant territories between major cerebral


arteries - cause cognitive deficits, visual
agnosia, weakness greater in proximal than in
distant muscle groups
RULED IN: RULED OUT:
Visual Disturbances
Headache

  No familial disposition (Familial

Hemiplegic Migraine)
 Hemiparetic
 No Scotoma

 No Slowly Developing
 Hemiplegic Hemianopia
 Absence of History of Migraine
 Aphasic
RULED IN: RULED OUT:
 (+) Evolution of
headache symptoms is
 Paresis
GRADUAL
 Hemianest
CT scan was
unremarkable
hesia  5 days PTA
 A vascular event secondary to real diseases of blood
vessel of the brain
 Occurs when the blood supply to a part of the brain is

suddenly interrupted by occlusion (an ischemic stroke)


or by hemorrhage (a hemorrhagic stroke)
 Stroke is literally a "BRAIN ATTACK”, caused when the

vital supply of blood, glucose and oxygen is cut off to


part of the brain

Incidence of stroke is highest
among ELDERLY and of
ADVANCE AGE.

It is more common among
MEN
 There are two main types/classification of
stroke.
1.) Ischemic Stroke
- caused by blockage of a blood vessel
- MORE COMMON (70-80%)
2.) Hemorrhagic Stroke
- caused by bleeding or involves the
rupture of a blood
vessel in or around the brain
- have a much higher fatality rate
- LESS COMMON (20-30%)
 Numbness, weakness, or paralysis of the
face, arm, or leg, especially on one side of
the body.
 Trouble seeing in one or both eyes

 Double vision, or things may look dim or

blurry
 Confusion or trouble understanding

 Slurred or garbled speech.

 Trouble walking

 Feel unsteady, dizzy, or clumsy

 Headache
 Aphasia
- inability to speak or
understand language from
involvement of Broca’s or
Wernicke’s area
 Apraxia

- altered voluntary
movements
 Visual field defect
 Memory deficits
-involvement of TEMPORAL LOBE
 Hemineglect

- involvement of PARIETAL LOBE


 Disorganized thinking, confusion,

 Anosognosia

- persistent denial of the existence


of a, usually stroke-related, deficit
Altered smell, taste, hearing,
or vision (total or partial)
Drooping of eyelid (ptosis) and
weakness of ocular muscle.
Decreased reflexes: gag,
swallow, pupil reactivity to light
Decreased sensation and
muscle weakness of the face
Balance problem and nystagmus
Altered breathing and heart rate
Weakness in sternecleido mastoid muscle
with inability to turn head to one side
Weakness in tongue (inability to protrude
and/or move from side to side)
 Advancing age
 Hypertension (high blood pressure)

 Previous stroke or Transient

Ischemic Attack (TIA)


 Diabetes

 High Cholesterol/Triglycerides

 Heavy Alcohol Drinker

 Cigarette Smoking

 Diet and Lifestyle

 Atrial Fibrillation
 The most common type of stroke
 It is a sudden loss of function due to loss of

blood supply to an area of the brain that


controls that function.
 It is characterized by the presence of a blood

clot that blocks the flow of blood to one area of


the brain, depriving that area of oxygen.
THROMBOTIC EMBOLIC
 accounts for 40-50% of all accounts for 20 percent of
cases of stroke. all cases of stroke.
 a blood clot originates in
 blood clot forms in one of
the brain's arteries, blocking the heart or in blood
vessels outside of the
blood flow to the brain.
brain and travels to one of
 In most cases, the artery the brain's arteries,
was already narrowed as a obstructing the flow of
result of atherosclerosis blood.
(fatty build-up).
Tests that view
the Brain, Spinal
Cord and Skull
 Uses magnetic field to produce 3D images
 Show the brain and spinal cord in great detail

 diagnose ischemic stroke, hemorrhagic stroke,

and other problems involving the brain,


brainstem, and spinal cord.
 uses x-rays to produce a 3-
dimensional image
 used to diagnose ischemic

stroke, hemorrhagic stroke,


and other problems of the
brain and brainstem.
Tests that view the
Blood Vessels that
Supply the Brain
 Ultrasound waves are used to take
a picture of the carotid arteries in
the neck
 Show the blood flowing to the brain

 Can show atherosclerosis


 Catheter is inserted in an artery in arm or leg
 A special dye is injected into the blood vessels

leading to the brain


  X-ray images show any abnormalities of the

blood vessels, including narrowing, blockage, or


malformations
 More difficult test than carotid doppler or MRA,

but the results are the most accurate.


Show the pattern

of electrical
activity in the
heart

Take a picture of your
heart and the circulating
blood. 

Ultrasound probe may
be placed on your chest
(trans-thoracic
echocardiogram, TTE) or

Routine test to
determine the
number of red blood
cells, white blood
cells, and platelets in
the blood

PT (Prothrombin time)
PTT (Partial
thromboplastin time)
INR (International
normalized ratio

Measure how quickly
 Most important test in emergency stroke
evaluation is glucose because levels of
blood glucose which are too high or too
low can cause symptoms which may be
mistaken for stroke
 Diagnosis of diabetes, which is a risk

factor for stroke


 Cholesterol, total lipids,
HDL, and LDL
 Elevated cholesterol is

a risk factor for heart


disease and stroke
 Ventilatory Anticoagulants
Support Antiplatelets
Antihypertensives
 Intravenous
Physical Therapy
Thrombolytic Occupational
Therapy therapy
 Mechanical
Removal of the
Embolus
 Maintain adequate tissue
oxygenation
 Prevent hypoxia and worsening of
injury
 Most common causes

▪ Partial airway obstruction


▪ Hypoventilation
▪ Aspiration pneumonia
▪ Atelectasis

Recombinant tissue
plasminogen
activator
 0.9mg/kg to a
maximum of 90mg
 10% given as a bolus

Reduces neurologic
deficit in patients
without CT evidence
of intracranial
hemorrhage
 Given within 3 hours
 Recent hemorrhage
 Inc. risk of hemorrhage

 Arterial puncture at a non-

compressible site
 Systolic above 185mmHg or

diastolic above 110mmHg



Cardiac source of
embolization

Intravenous heparin
while warfarin is
introduced

INR 2.0-3.0 target for

Aspirin (must be given w/in
48h of an acute ischemic
stroke.)
 MOA: Inhibits prostaglandin
synthesis, preventing formation
of platelet-aggregating
thromboxane A2.
 May be used in low dose to
inhibit platelet aggregation and
improve complications of
 MOA: Selectively inhibits ADP
binding to platelet receptor and
subsequent ADP-mediated
activation of glycoprotein
GPIIb/IIIa complex, thereby
inhibiting platelet aggregation
 Dose: 75 mg/d PO qd

Lowering BP of
hypertensive patients
during acute phase
should be avoided

If systolic pressure
>220mmHg

Impaired motor
function

Passive
movements at an
early stage helps
Improve morale
and motor skills
Speech therapy
for expressive
dysphasia or
 2009 Current Medical Diagnosis & Treatment 48th edition;
Stephen J. McPhee, Maxine A. Papadakis
 Harrison’s Principle of Internal Medicine, 17 Edition
th

 Clinical Neuroanatomy, Snell 6 Edition


th

 G & A Notes, Plama et. Al. 2 Edition


nd

 Stroke, Pathophysiology, Diagnosis and Management, 4 Edition


th

 Principles of Neurology, Adams and Victor’s, 8 Edition


th