Case Writeup Albert Labores 9.24.2010 Stroke

Anthony Regalado Module Preceptor: Dr. JP Reyes

Neurology 9/24/2010

Identification Full name: Albert Madamba Labores Gender: M  Age/Birthdate: 66 y/o Race: Filipino Civil Status: Married Place of Origin: not stated Occcupation: Manager, teacher Religion: Not stated Literacy Level: Literate Informant: “Eldest daughter” Relation to Patient : Daughter Reliability: Excellent Chief Complaint: Difficulty in speech production History of Present Illness Patient was apparently well until 9 months PTC (January 12, 2010) in Kuala Lumpur, when the patient had an acute syncope attack and manifested with unusual speech, wherein he was described as talking “like a Martian” when he talked while mixing words from the different languages that he knows. The patient apparently experienced a headache the night before, which he apparently ignored. After the syncope attack, patient was brought to the Emergency Room in a nearby hospital and was scheduled for an MRI which he did not take.  The patient instead went to another clinic for a checkup, and was referred back to the hospital with an impression of acute ischemic stroke as based on the patient’s manifesting manifesting signs and symptoms. Upon admission in the hospital, he was given recombinant tissue-type plasminogen activator activator (rt-PA) and sedation. He was confined to the ICU for 5 days and to a private ward in 6 days, where his status gradually improved. He escaped from the hospital ahead of his discharge period. At home, the patient continued his medications of Neuroaide 3x/day (a supplement, for adjuvant therapy), Epelim (an anticonvulsant), Januvia (an antidiabetic), antidiabetic), and an unrecalled medicine for hypertension. At this time, patient still had minor problems in speech and understanding people with heavy accents, but he did not present with any motor deficiencies. deficiencies. Patient had a dietician which prescribed an appropriate diet to control his pre-existing hypertension hypertension and diabetes. He stopped taking Neuroaide 2 months PTC, for undisclosed reasons.

3 days PTC in the Philippines, Philippines, patient experienced sudden onset of difficulty in speech production again, which occurred after eating a heavy lunch with his relatives. He was rushed to the Emergency Room of the Medical City. According to the attending physician physician (Dr. Reyes), workup upon arrival revealed that the patient was awake but had difficulty following commands, and manifested with right eye deviation, slurring of speech, wordfinding difficulties, right arm weakness (grade 2/5), and generalized seizure. Patient was also said to have difficulty in hearing. Diazepam was administered to the patient, which relieved him of his right arm weakness. An MRI was also done, with the results still unknown as of the consult. Other medicine given or diagnostic procedures done to the patient were not disclosed. 1 day PTC, patient patient was reported to have slight slight improvement in speech production. Past Medical History According to the patient’s daughter, the patient did not have any notable childhood illnesses. He had previous cases of gout, laryngitis, bronchitis, and vertigo. He was also confined in a hospital for a mild heart attack when he was 30. Patient is currently diagnosed with diabetes and hypertension, both treated with medication. Family History See genogram.  Additional notes:

Anthony Regalado Module Preceptor: Dr. JP Reyes

Neurology 9/24/2010

Positive family history of hypertension, diabetes, asthma and allergies. Patient is 66 years old. His wife is 70. Their children are aged 41, 36, and 34, respectively. Personal and Social History  The patient graduated college with a degree in Economics in Ateneo I ntramuros, and has a doctorate. He currently works as a manager in an international company based in Kuala Lumpur, Malaysia, and as a teacher in the Philippines. He frequently flies to and from both countries for his work. He was said to have been a heavy smoker (unknown pack-years) but stopped after his first stroke episode in January. He is also an occasional red wine drinker. Patient denies illegal drug usage. He is suspected to be right-handed, since the right hand was primarily used in writing. Psycho-socio-religious context  From the history of the patient, it can be ascertained that the patient and his family belongs to the upper socio-economic classes. As such, the choice for the diagnostic and treatment modalities available to the patient is somewhat more flexible. However, the costeffectiveness and necessity of the modalities should still be considered so that unnecessary costs may be avoided. Review of Systems Given the patient’s difficulties in hearing and speech production, review of systems was not done. Mini-mental Status Exam (MMSE) MMSE revealed normal findings in orientation, memory (except short-term memory, which was not tested), language and praxis, reading and following directions, copying, fund of  knowledge, abstract thinking, and insight and judgement. It should be noted that most of  the questions given for the MMSE were written down for the patient to read, given that he had trouble hearing the questions. Physical Examination Vital signs: BP: 150/70 HR: 80 beats/min (normal) RR: 25 cycles/min (tachypnic) Temp: 36.1⁰C Height: not obtained Weight: not obtained BMI: n/a Overall condition : Patient was not in distress Stature: appears well; patient is ambulatory, coherent and oriented Neurologic Exam: CN 1 – not done CN 2, 3, 4, 6– visual actuity measured at 20/60, eyes soft on tonometry, positive ROR reflex for both eyes, full visual fields on confrontation, pupils equally round and reactive to light (approx. 4 mm in dilataion and 1mm in constriction), accommodation and consensual dilation present, intact extraocular movements CN 5 – intact sensory; no weakness of masseter and temporal muscles CN 7 – intact sensory; no facial weakness noted CN 8 - Screening test revealed better sound reception in right ear. Weber’s test revealed sound lateralization in the right ear; Rinne’s test revealed longer bone than air conduction in the left ear (abnormal, may indicate conduction hearing loss) and longer air that bone conduction in the right ear (normal). Patient had a history of stroke. CN 9, 10 – Normal palatal elevation, no deviation of uvula noted. Taste sensation tests not done. Normal swallowing. Gag and cough reflexes not elicited. CN 11 – Normal sternocleidomastoid and trapezius muscle strength (5/5)

Anthony Regalado Module Preceptor: Dr. JP Reyes

Neurology 9/24/2010

CN 12 – normal tongue movements; no deviations noted. Skin: Good skin turgidity, no paleness, discolorations, scars and other unusual skin conditions noted. HEENT : Head: unremarkable Eyes: unremarkable; normal sclera and conjunctiva. Patient claims that he uses glasses. See Neurologic exam for other eye findings. Ears: No tenderness elicited on palpation. Otoscopy not done. See Neurologic exam for other ear findings. Nose: unremarkable; rhinoscopy not done. Neck: unremarkable; neck veins not distended  Throat: unremarkable; no masses, lesions or dental carries noted in oral cavity and pharynx. Swallowing was normal. Normal palatal elevation without deviation of uvula.  Anterior chest : not examined Lungs: not examined Heart : not examined Upper Extremities: All upper extremities 5/5 on muscle strength grading.  Abdomen/Inguinal: not examined Perineum/Rectal : Digital rectal exam was not done. Lower extremities : Normal reflexes. Negative for extensor plantar reflex. All lower extremities 5/5 on muscle strength grading. Pre-workup Discussion Salient features : Patient presented with acute onset of difficulties in speech, hearing, and right arm weakness with right eye deviation and seizures. Patient can comprehend written or spoken directions. Patient’s hearing and speech somewhat improved on 2 nd day of  admission. Weber’s test revealed sound lateralization in the right ear; Rinne’s test revealed longer bone than air conduction in the left ear (abnormal, may indicate conduction hearing loss) and longer air that bone conduction in the right ear (normal). Patient is suspected to be right-handed, since the right hand was primarily used in writing. Patient is in the “elderly” age range (66 years old). Clinical Impression : Broca’s aphasia, secondary to right middle cerebral artery occlusion resulting in acute ischemic stroke of right hemisphere; suspected right ear sensorineural hearing loss. Pathophysiology of Clinical Impression: Ischemic stroke can be caused by a number of factors such as thrombosis or embolism. Given the patient’s long-standing hypertension (which he claims to be treated via medicine although there was no proof of regular medicine-taking), it is highly possible for thrombosis or embolism to occur. Thrombus or emboli deposition in one of the branches of the middle cerebral artery may cause the blockage of blood flow to the brain areas it supplies, resulting in infarction and concomitant neurologic disturbance. If the M2 or M3 branches of the middle cerebral artery supplying the dominant hemisphere are blocked, structures that they supply, such as Broca’s area, may be hypoperfused. This will effectively lead to Broca’s aphasia whose manifestations are consistent with the initial presentation of the patient; namely difficulty in speech production but no disorders in speech or written comprehension. Normally, aphasia presents if the dominant hemisphere is affected by the infarct. A clue in finding out which hemisphere was affected is to look at the side of eye deviation during the occurrence of a stroke, since the eyes usually deviate to the side of the lesion. Since the patient’s eyes deviated to the right, it is highly probable that the lesion is found in the right

Anthony Regalado Module Preceptor: Dr. JP Reyes

Neurology 9/24/2010

hemisphere; thus indicating that the right middle cerebral artery is the one that was infarcted. Since the patient presented with aphasia, it is possible therefore for him to belong to the minority of people who are right hemisphere-dominant.  The patient’s hearing difficulty may also imply that part of the hearing center of the brain that is found in the temporal lobe may have been affected as well, resulting in sensorineural hearing loss of the right ear. This is highly possible given the somewhat close proximity of  the hearing center to Broca’s area. Although the Weber and Rinne tests done yielded conflicting results to this suspicion, it is highly possible for the patient to have simply misheard or not understand the directions of the tests. Literature review to support impression: “Broca’s aphasia, also termed expressive or motor aphasia, describes the ability to comprehend written or spoken language, with nonfluent or impaired expression of either spoken or written language... The infarct responsible for  Broca’s aphasia encompasses the insula and frontoparietal operculum... M2 is the segment [of the middle cerebral artery] that runs along the insula, and M3 follows the operculum superior to the insula”  (Slater, 2010).

Differential diagnoses: Disease

Rule In

Rule Out

Wernicke’s Aphasia

Initially presented with difficulty in following commands, initially had inappropriate answers to questions during history-taking

Hypoglycemia

History of diabetes (may be due to not taking medicine or taking too much medicine), presents with possible neuroglycopenic symptoms (shakiness, confusion, difficulty w/ concentration, weakness) that may manifest as difficulty in speaking Initially presented with speech deficits and seemingly auditory comprehension (in the form of  difficulty in following commands), also difficulties in naming and repetition

Understands written language; accompanying hearing difficulty may explain inability to follow commands and inappropriate answers Continuing symptoms despite feeding and (assumingly) appropriate glucose control in hospital

Global Aphasia

Rare occurrence with right hemisphere lesions, rarely occurs without hemiparesis (which patient does not exhibit)

Related psycho-social-religious problems Given that the patient belongs to a higher socio-economic class, the best diagnostic and treatment modalities available are usually afforded to the patient. However, the necessity and efficacy of the treatment should always be kept in mind to reduce unnecessary costs which could add up in the long run. The propensity of the patient to delay treatment, or escape from the hospital once he feels better even if this is ahead of the prescribed schedule, should be addressed since this could result in treatment failure in the future. Diagnostic Workup Pertinent laboratory and ancillary tests :

Anthony Regalado Module Preceptor: Dr. JP Reyes

Neurology 9/24/2010

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On arrival of patient to the ER, always start by checking for airway, breathing and circulation status and address these as necessary - Once patient is stable, check for possible underlying causes of the stroke via electrocardiography (to check for rhythm disorders that may increase risk for embolism), chest radiography (to check for possible lung Ca metastasis), O2 and blood gas measurements, urinalysis, and blood studies (CBC, electrolyte and glucose values, etc). Imaging studies: - CT scan is usually used as an initial imaging modality given its relatively lower price, easier accessibility, good resolution, rapid testing time, and sensitivity in determining whether the stroke is ischemic or hemorrhagic in nature. CT scan may also detect presence of blocked cranial vessels (which may appear hyperdense) - MRI may also be done to clinch the diagnosis of stroke, especially in the first few hours of symptom onset. Diffusion-weighted MRI is recommended for faster testing time and better resolution than CT scan - Transcranial Doppler ultrasonography may be used as a noninvasive method to check the patency of the major intracranial vessels such as the MCA. Similarly, carotid duplex ultrasonography may also be used to explore other sources of embolic stroke, and along with Doppler ultrasonography may be used to detect possible sites of stenosis. Therapeutic Management Definitive management : - Surgery is usually not done unless a space-occupying lesion is the causative factor for the patient’s symptoms. Supportive/adjuvant/palliative management : - For acute stroke, recombinant tissue-type plasminogen activator (rt-PA) is given to lyse the embolus causing the blockage in the cerebral artery affected. Hemorrhagic etiologies should first be ruled out before administering this drug Efficacy of the drug depends on how early it was given; studies have shown o that administering the drug within 3 hours of symptom manifestation significantly improves the prognosis of the patient - For ischemic causes of stroke, the blood pressure may be kept slightly elevated initially to promote adequate blood flow to the brain - Supportive treatment (fluid replacement, adequate nutrition, etc) should be given to the patient as well - Medication to treat/maintain pre-existing conditions (such as diabetes and hypertension for the patient) should be continued once patient stabilizes - Preventive measures such as anticoagulant therapy (ex. aspirin) can be started in order to reduce occurrences of thrombus formation - Upon discharge, appropriate rehabilitation programs should be provided in order for the patient to be restored as close as possible to his status prior to the stroke incident. This may include physical, occupational, speech and recreational therapy, depending on what the patient needs. Management to related psycho-social-religious problem  The patient should be advised regarding staying in the hospital for the entire treatment schedule in order to ensure that his condition will be treated completely. Just because the patient already feels better does not rule out his disease from relapsing or progressing; as such it is important to wait for the doctor’s recommendation for discharge before leaving the hospital. Preventive measures

Anthony Regalado Module Preceptor: Dr. JP Reyes

Neurology 9/24/2010

 To prevent future occurrences of embolism and thrombus formation, antiplatelet therapy may be given. Usual drug choices include cyclooxygenase inhibitors such as aspirin, clopidogrel, or ticlopidine. Anticoagulant therapy may also be given to prevent recurrent or pre-existing thromboembolism; warfarin is usually used for this. Prognosis  The prognosis of acute ischemic stroke depends on how early it was detected and treated. Studies have revealed that administration of rt-PA within 3 hours of symptom manifestation would usually entail a good prognosis. Any longer than this may result in permanent neurologic sequelae or, in extreme cases, possibly death.

Sources:

Kasper, D., A. Fauci, D. Longo, E. Braunwald, S. Hauser, and J. J ameson. 2005. Harrison’s Principles of Internal Medicine, 16 th Edition. McGraw-Hill Medical Publishing Division. Kumar, V., A. Abbas, and N. Fausto. 2006. Robbins and Coltran Pathologic Basis of Disease. Elsevier. Morris, Dexter, M.D. Stroke. Available at: http://www.emedicinehealth.com/stroke/article_em.htm#Stroke Overview. Last accessed: 30 September 2010. Slater, Daniel, M.D. Middle Cerebral Artery Stroke. Available at: http://emedicine.medscape.com/article/323120-overview. Last accessed: 30 September 2010.