Patient Management

Seminar 3

STROKE
by
Emylia Zailan
Shalini Soorya
Tan You Siang
Zahran Borhan

Patient Details

Name: Mr. Manimaran a/l Ellan

Age: 42 years old
Gender: Male
Race: Indian
Address: Kajang
Date of Admission: 9/12/13
Date of Clerking: 13/12/13
Historian: Patient's wife

Chief Complaint
Patient with underlying hypertension (poorly
controlled) diagnosed 2 years ago
presented with altered behaviour that
started 1 week prior to admission.

History of Presenting Illness

Altered behaviour was noticed by his wife.
Patient frequently mumbling to himself
and reluctant to respond when people
talked to him.
For the past 1 week family members had
difficulty in communicating with him as he
appeared confused when people talk to
him.
This was the first episode patient acted
this way.

 Preceding the onset of altered behaviour

patient complaint of severe headache for
3 days, which was generalized and
throbbing in nature.
It was temporarily relived with panadol and
also traditional medication he was taken.
Patient is right hand dominant.
He is a chronic smoker of 26 pack years.
Patient had no syncopal episodes, no
dizziness,no episodes of seizure, no limb
weakness, no slurring of speech, no
episodes of chocking food and no urinary
or bowel incontinence.

 Patient did not has any fever, was not

jaundiced, has no episodes of palpitation,
has no episodes of trauma, no loss of
weight or loss of appetite and no loss of
vision.
Previous functioning, patient able to
converse with people as normal and is
independent in taking care of himself.

Past Medical & Surgical Hx

- 1st hospital admission
- 2 years ago had an episode of severe headache
and was brought into A&E Serdang, the
recorded BP was very high.
- Since then patient was diagnosed with
Hypertension but diffaulted follow up and did not
take any anti-hyeprtensive medication.
- Patient has no past history of psychiatric disoder.
Drugs & Allergies Hx
- Took papaya leave juice.
- Has no known food or drugs allergies.

Family Hx
- Patient's mother has DM and HT.
- No one in the family has similar episode.
Social History
- Patient currently working as a planter in his
brother plantation.
- He is staying in Kajang with his wife and 3
children.
- His wife works as cleaner in Hospital Kajang.
- Financially supported by his wife and children.
- Patient is a chronic smoker & an alcoholic of 14
units/ week. (beer 2 cans/day)
- Not involved in any illicit drug used.

Physical Examination
Patient was sitting on the bed. His is obese with BMI: 32. He
was concious, alert however he appeared confious and
disorientated to time, person and place.
He looked comfortable, not grossly in pain, no facial
assymmetry observed and no awkard posturing of the limbs
seen.
Hands were warm, nicotine stain on his fingers, CRT< 2 sec,
no finger clubbing, no stigmata of IE or liver disease.
Conjuctiva was pink, sclera was non-icteric.
He has normal gait and able to mobilised without any
assistance.
Vital Signs:
BP: 170/130 mmHg
PR: 100 beats/min, regular rhythm, good volume.
RR: 17 breath/min
T: 37.2 (afebrile)
SPO2: 99%(under room air)

1. Mini Mental Status Examination

(MMSE)
- Unable to conduct the examination as
patient unable to cooperate.
- Score: 0/30

2. Systemic Examination
Syste
ms

Findings

CNS

Cranial Nerves: All cranial nerves are intact except CN: VIII
unable to assess.
Sensory: All dermatomes sensation are intact
Motor: Upper Limbs: 5/5
Lower Limbs: 5/5
- Tone are normal
- Reflexes are present and normal
- Babinski sign: Negative

CVS

Apex beat palpable at 5th ICS, Mid-clavicular line. No palpable

thrill and no parasternal heave.
On auscultation: S1 & S2 was heard. No additional heart
sound and murmur was heard.
- No carotid bruit.
- No bibasal creptitations of the lungs
- No bilateral pitting edema.

RS

- Chest expansion was equal

- On percussion all zones were resonant

Systems
GIT

Findings
- Abdomen was distended
- On palpation abdomen was soft and non-tender. No
palpable mass.
- On auscultation bowel sound was heard, no aortic and
renal bruit was heard.

Fundoscopy findings:
Right eye: red reflex normal, no increase in cup-disc ratio, no
haemorrhages seen.
Left eye: red reflex normal, normal cup-disc ratio, no haemorrhages
seen.

Summary
42 years old right hand dominant Indian
man with underlying uncotrolled HTN
presented with altered behaviour that
started 1 week ago, he appeared
confused, disorientated and has difficulty
in understanding command. However he
able to speak clearly and other motor and
sensory functions are preserved. He has
no known psychiatric history.

Investigations
1) Blood Investigations
Full Blood Count (FBC)
9/12/13

10/12/13 13/12/13

Hb

18.6

16.4

16.5

Hct

56.9

49.2

48.9

Platelet

162

224

2.51

WCC

10.5

11.2

9.0

59

51

Neutrophi 63
l

Renal Profile
9/12/13

13/12/13

Urea

3.3

2.7

Na

135

133

3.6

4.6

Cl

101

103

Creatini
ne

81

70

Mg

0.78

1.15

Po4

1.00

1.20

Ca

2.56

2.40

Lipid Profile
11/12/13

13/12/13

Cholesterol

6.40

6.10

TG

1.67

1.20

LDL

5.48

4.64

HDL

1.01

0.91

Liver Function Test (LFT)

9/12/13

12/12/13

Total
Protein

85

76

Albumin

41

37

Globulin

44

59

A/G

0.93

0.44

ALT

19

21

ALP

82

69

TSB

19.2

21.2

 UFEME
11/12/13
Blood

-ve

Ketone

-ve

Protein

-ve

Nitrite

nil

Sugar

-ve

Leucocyte

-ve

FBS: 4.66 mmol/L

ECG

CT Scan

 CT Brain findings:
- Large area of left temperoparieto- occipital infarct noted
causing mass effect to left lateral ventricle and left
sylvian fissure.
- There is also effacement of the cortical sulci noted at left
cerebral hemisphere extending to the vertex indicating
cerebral edema.
-There are also multiple small infarcts seen at posterior
limb of bilateral external capsule, both corona radiata
and bilateral basal ganglia.
- No intracranial haemorrhage.
- No significant midline shift. No uncal herniation.
Impression:
Large left temperoparieto-occipital infarct wuth left-sided
cerebral edema
Multifocal small infarcts. No intracranial haemorrhage.

MANAGEMENT

At the emergency department

BP: 193/117 mmHg
His blood pressure was monitored every 2 hourly. He was started
on T. Amlodipine 2.5mg.
His systolic blood pressure remained less than 200 mmHg.
Other vitals were stable
At the ward
T.Aspirin 150mg OD
T. Piracetam
T. Simvastatin 20mg ON
T. Amlodipine
T. Risperidone 1mg OD

Factors

CPG recommendation

Hospital Management

Airway and
Breathing

1. Clear airway and adequate

oxygenation.
2. If ICP is severely increased
Elective intubation

Mobilization

Mobilize early to prevent

complications.

Blood Pressure

1. Blood pressure reduction should On admission his pressure was

not be drastic.
193/117mmHg.
2. Do not treat if systolic
< 220mmHg diastolic < 120mmHg.

Blood Glucose

1. Treat hyperglycaemia
(RBS>11mmol/l) with insulin.
Treat hypoglycaemia (RBS < 3
mmol/l) with glucose infusion.

He was normoglycemic

Nutrition

1. Perform a water swallow test.

(Insert a NGT if patient fails the
test)

Water swallow test was done.

Patient could swallow water.

Fever

Use anti-pyretics to control

elevated temperatures.

Patient was afebrile

Factors

Recommendation

Hospital Management

Infection

1. If patient is febrile, look for source

of infection
2. Treat with
appropriate antibiotics early.

Patient was afebrile upon

admission.
Temperature: 37 degree
celcius

Raised ICP

1. Hyperventilate to lower ICP.

Patients ICP was not raised

2. Mannitol (0.25 to 0.5g/kg) IV

(20mins) lower ICP - given every
6 hours.
3. Hydrocephalusdrain CSF
intraventricular catheter
4. Hemicraniectomy and surgical
decompressive therapy within 48
hours of onset of symtpoms to
control ICP and prevent herniation

Reperfusion agents
Agents

CPG criteria

For this patient

rt-Pa

Intravenous rt-PA (0.9mg/kg, maximum

90mg), with 10% of
the dose given as a bolus followed by a
60-minute infusion, is recommended
within 4.5 hours of onset of ischaemic
stroke

Patient was started on

aspirin

Aspirin

Start aspirin within 48 hours of stroke

onset.
Use of aspirin within 24 hours of rt-PA is
not recommended

Agents

CPG criteria

Hospital management

Anticoagulants

The use of heparins is not

routinely recommended

Patient was not started on

anticoagulants.

it does not reduce the

mortality in patients with acute
ischaemic stroke.

Neuroprotective
Agents

Not recommended.
A large number of clinical trials
has produced negative results.

Stroke Unit
Stroke unit
A stroke unit is a dedicated unit in the
hospital exclusively managing stroke
patients.
A multidisciplinary team that provides care
throughout 24 hours.
They consist neurologist, geriatrician or
general physicians with interest in stroke),
medical rehabilitation physician,
pharmacist, nursing, physiotherapy,
occupational therapy and speech therapy.

This patient is going to have a stroke audit

in Hospital Serdang.

Referral To The Psychiatric Team

The patient was noted to be speaking to
himself or uttering incoherent words when
asked a question.
In the ward, he was started on T.
Risperidone 1mg OD for 7 days (and
PRN)

Before discharge and follow up plan

GCS did not deteriorate further
He is going to be referred to the neurology
department of HKL for further
management.
He was discharged on Amlodipine,
Simvastatin, Risperidone
Follow up at the KK in 2 weeks time.

Evidence Based Medicine

Effects of Admission Hyperglycemia on Stroke Outcome in

Recombinant Tissue Plasminogen ActivatorTreated Patients
Hyperglycemia before reperfusion may in part counterbalance the beneficial
effect of early restoration of blood flow, which translates into a worse
outcome in hyperglycemic patients despite tPA-induced recanalization.

Reference:
Jos Alvarez-Sabn,Carlos A. Molina,Joan Montaner,Juan F. Arenillas,Rafael
Huertas,Marc Ribo,Agusti Codina,Manuel Quintana. Effects of Admission
Hyperglycemia on Stroke Outcome in Reperfused Tissue Plasminogen
Activator -Treated Patients. Stroke 2003, Journal of the American Heart
Association.
Online resource: http://stroke.ahajournals.org/content/34/5/1235.short

Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial
infarction, and stroke in high risk patients

Aspirin (or another oral antiplatelet drug) is protective in most types of

patient at increased risk of occlusive vascular events, including those with an
acute myocardial infarction or ischaemic stroke, unstable or stable angina,
previous myocardial infarction, stroke or cerebral ischaemia, peripheral
arterial disease, or atrial fibrillation. Low dose aspirin (75-150 mg daily) is an
effective antiplatelet regimen for long term use, but in acute settings an initial
loading dose of at least 150 mg aspirin may be required. Adding a second
antiplatelet drug to aspirin may produce additional benefits in some clinical
circumstances, but more research into this strategy is needed.
Correspondence to:
Antithrombotic
Trialists' Secretariat,
Clinical Trial
Service Unit,
Radcliffe Infirmary,
Oxford OX2 6HE
www.ctsu.ox.ac.uk
BMJ 2002;324:7186

Blood Pressure Management in Acute Intracerebral Hemorrhage

Relationship Between Elevated Blood Pressure and Hematoma
Enlargement

Target SBPs of 160 mm Hg were significantly associated with

hematoma enlargement compared with those of 150 mm Hg
(P=0.025). The finding suggest that elevated BP increases the risk
of hematoma enlargement. Efforts to lower SBP below 150 mm
Hg may prevent this risk.

Reference:
Kazuhiro Ohwaki, Eiji Yano, Hiroshi Nagashima, Masafumi
Hirata, Tadayoshi Nakagomi, Akira Tamura.Stroke2004, Journal of
American Heart Association
Online Resource: http://stroke.ahajournals.org/content/35/6/1364.short

Management of Haemorrhagic
Stroke

Mx of Intracerbral Haemorrhagic stroke

General measures:
Ensure clear airway and adequate oxygenation to prevent hypoxia
and potential worsening of the neurological injury .
Intubation may help some patients with severely increased ICP.
(Class III; Grade C)
FBC,Random blood glucose, Urea and electrolytes, ECG, CT scan
Initial monitoring and management of ICH patients should take
place in ICU with physician and nursing ICU expertise. (Class I;
Grade: B)
Blood Pressure Control in Severe Hypertension
Antiplatelet and anti coagulant are contraindicated. Patient with ICH
whose INR is elevated due to oral anticoagulant, early
administration of fresh frozen plasma and Vitamin K to reverse this
coagulopathy is recommended. (Class 1; Grade C)

Mx of Intracerbral Haemorrhagic stroke

Rapid neuroimaging with CT is recommended to distinguish
ischemic stroke from ICH and determine the exact site (Class
I; Level of Evidence: A)
CT angiography and contrast-enhanced CT may be
considered to help identify patient at risk of hematoma
expansion (Class IIb; Level of Evidence: B)
CT or MRI angiogram/venogram can be useful to evaluate for
underlying structural lesions, including AVM, tumours, and
cerebral vein thrombosis. (Class IIa; Level of Evidence: B)

In patient presenting with a systolic BP of 150 to

220 mmHg, acute lowering of systolic BP to 140
mmHg is probably safe (Class IIa; Grade B)

 Patient with a GCS score of less or more than 8, evidence of

transtentorial herniation, or those with significant Intraventricular
Heamorrhage (IVH) might be considered for ICP monitoring.
(Class IIb; Grade C)
Glucose should be monitored and normoglycemia is
recommended (Class I; Grade: C)
Most patient require 2,000 to 2500 ml fluid per 24 hrs.
Use anti-pyretics to control elevated temperatures. (Class II-b;
Grade B)
Patient with ICH should have intermittent pneumatic compression
for prevention of venous thromboembolism in addition to elastic
stockings (Class I; Grade B)

 Surgical evacuation of hematoma may be indicated in

surgically accessible cerebral hematomas causing
significant mass effect (for example >30 ml clot or a
midline shift on the CT scan). (Class IIb; Grade B)

Mx of Subdarachnoid Hemorrhage
General investigations and supportive care as in
Intracerebral Heamorrhage
Non contrast CT scan, which, if non diagnostic,
should be followed by Lumbar Punture (LP)
(Class I; Grade B)
CT Angiogram may be considered in the workup
of Aneurysmal Subarahnoid (aSAH) to help
guiding the decision for type of aneurysm repair.
(Class IIb; Grade C)

Prevention of cerebral vasospasm

Nimodipine is given to prevent and treat vasospasm
(narrowing) of arterial cerebral arteries which usually
occur 2-3 days after the initial haemorrhage, peak at
about day 7-10 and resolving after 21 days. (Class I;
Grade A)
Transcranial doppler or cerebral angiogram may be
useful to confirm cerebral vasospasm.
The present rescue therapies, which include triple H
therapy HHH, (hypertension/hypervolemia/
hemodilution).
Hypervoleamic volume expansion is accomplished by
administering 5& albumin or artificial colloids. If spasm is
still a problem even after hypervoleamia, BP can be
raised with inotropic agents such as IV dopamine,
dobutamine.

Surgery
Patient who undergo surgical clipping or endovascular
coiling of the ruptured aneurysm generally fare better
than those who are treated medically because surgery

 Hydrocephalous
aSAH-associated acute symptomatic
hydrocephalus may warrant
ventriculostomy by External Ventricular
Drainage (EVD)
aSAH-associated chronic symptomatic
hydrocephalus may warrant permanent
ventriculoperitoneal shunt

QUESTIONS

1.)65 year-old patient known case of DM and hypertension.

Presented with a speech impediment. He is not able to repeat
anything that is said to him or to name objects. However he has
preserved fluency of speech and good comprehension of spoken
and written language. No other neurological sign. Name the
most likely condition.
A.Brocas aphasia
B.Conduction aphasia
C.Global aphasia
D.Transcortical sensory aphasia
E.Wernickes aphasia

2.)56 year old man,diagnosed with subaranoid hemorrhage

following cerebral aneurysm in anterior circulation. Endovascular
coiling was done instead of surgical clipping. 1 week later,he
suffered rapid decline in mental status. New infarct in confirmed
with MRI. Based on the history and time course, what is the
most likely cause of new infarct?
A.Atherosclerosis
B.Cardiogenic thromboembolism
C.Hydrocephalus
D.Vasospasm

3.)70 year old african-american man presents with new onset

aphasia and left ided homonymous hemianopsia. Results of
CT brain showed below. Which vascular territory is involved?

A.Anterior cerebral artery

B.Basilar artery
C.Lacunar territories
D.Middle cerebral artery
E.Posterior cerebral artery

CT Brain (Q3)

4.)55 year old man presents to ED with 2 hours hx of incresing

headache, nausea and vomiting. Known case of DM and
hypertension. His heart rate is 41/min,BP150/74mmHg,RR
12/min, and temperature 37C. He is alert and protecting his
airway. Neurological examination revealed left sided weakness
and dilated pupil. After ordering the CT brain. What is the 1 st
priority for this patient?
A.Administer anti-emetics
B.Administer thrombolytic agents within 3 hours
C.Aggressive blood pressure management
D.Frequent blood sugar level measurement
E.Neurosurgical consultation

EMQ 1-Reperfusion Therapy

a)Intravenous rTPA
b)Intra-arterial Thrombolysis
c)Streptokinase
d)Endovascular mechanical thrombolectomy
e)Reperfusion therapy
f)No reperfusion therapy is
indicated/contraindicated

EMQ 1-Reperfusion therapy

57 year old single man, brought by social worker to ED with 2 days history of
right sided limb weakness. A diagnosis of left cerebral infarction was made.
45 year old man, poorly controlled hypertensive patient presented to ED with
loss of consciousness. The blood pressure on presentation is
220/140mmHg. A CT brain revealed hyperdense lesion at right cerebral
hemisphere.
65 year old right handed dominant lady, Known case of diabetic on insulin
brought to ED with facial asymmetry ,right upper limb weakness and global
aphasia noted 3 hours prior to admission. Had history of recent myocardial
infarction 2 months ago.
58 year old chronic smoker, brought to the hospital with 4 hours history of
altered behavior and receptive aphasia. CT brain revealed hypodense
lesion at occipitoparietal region of the left cerebral.

EMQ 1:Loss of Consciousness

a)Subdural hematoma
b)Encephalitis
c)Subarachnoid hemorrhage
d)Status epilepticus
e)Meningitis
f)Intracerebral hemorrhage
g)Hypoglycemia
h)Diabetic ketoacidosis
i)Carbon monoxide poisoning
j)Heroin overdose

EMQ 1:Loss of Consciousness

18 year old male who is an insulin dependent diabetic ,unconscious in his room
On examination he does not look dehydrated, he is not rousable even when
painful stimuli are used, his respiratory rate is 15 breaths per minute and not
deep.
56-year-old male who has hypertension for which he has not been taking
medication presents with a history of headache, nausea and vomiting and left
sided weakness of sudden onset.
45-year-old female presents with a history of sudden onset occipital headache
followed by a deteriorating level of consciousness. On examinationthere is
neck stiffness.
80-year-old male who has been having frequent falls presents with a fluctuating
level of consciousness noted by the carers at the nursing home he lives in. On
clinical examination there are no neurological signs.

Take Home Message

References