You are on page 1of 1

STROKE CASE Case 1 A 42-year-old teacher has to retire from the classroom abruptly on account of the most sudden

and severe headache she has ever had in her life. She has to sit down in the staffroom and summon help on the phone.The school secretary calls for an ambulance as soon as she sees the patient, who is normally very robust and is clearly in extreme pain. On arrival in the hospital A & E department, the patient is still in severe pain. Her BP is 160/100 and she shows marked neck stiffness but no other abnormalities on general or neurological examination. A clinical diagnosis of subarachnoid haemorrhage is made. She is admitted to the medical ward. a. What investigations would you arrange? b. How would you proceed now? Case 2 A 55-year-old publicans wife is known to suffer from significant hypertension. She is receiving medication from her GP for this, but is not at all compliant. She smokes, and partakes of a drink. She is very overweight. She suddenly collapses in the kitchen. She is unrousable except by painful stimuli, is retching and vomiting, and does not move her left limbs at all. a. What is the most likely diagnosis? She is taken to hospital by ambulance. Her physical signs in A & E are: obese; BP 240/140; no neck stiffness; no response to verbal command, and no speech; eyes closed, and deviated to the right when the eyelids are elevated; no movement of left limbs to painful stimuli; withdrawal of right limbs from painful stimuli; extensor left plantar response. b. What is the most likely diagnosis? c. What investigations would you arrange? d. What would you tell her husband? Case 1 a. CT brain scan, which in this instance showed no definite abnormality, just a suggestion of subarachnoid blood. Lumbar puncture produced unequivocal, uniformly bloodstained CSF. b. Neurosurgical referral. Cerebral angiography, which demonstrated a single posterior communicating artery aneurysm on the left. The patient was started on nimodipine and proceeded to surgery without delay. A clip was placed around the neck of the aneurysm. The post-operative period was complicated by a transient right hemiparesis, which recovered completely after 10 days. The patients BP settled to 120/80. She has had no further problems. Case 2 a. Right-sided intracerebral haemorrhage. b. Right-sided intracerebral haemorrhage. c. CT brain scan, which shows a large clot of blood centred on the right internal capsule. ECG and chest X-ray both confirm left ventricular hypertrophy. d. He needs to know that his wife is in a grave situation, with regard to both survival (comatose, obese lady in bed) and useful neurological recovery. All appropriate care was given to this woman, but she developed a deep vein thrombosis in her left calf on day 2, and died suddenly from a pulmonary embolus on day 4.