BL-1 Monday

“A 59-year-old Hispanic man presented with right upper and lower extremity weakness, associated with facial
drop and slurred speech starting 2 hours before the presentation. He denied visual disturbance, headache, chest
pain, palpitations, dyspnea, dysphagia, fever, dizziness, loss of consciousness, bowel or urinary incontinence,
or trauma.

His medical history was significant for uncontrolled type 2 diabetes mellitus, hypertension, hyperlipidemia,
and benign prostatic hypertrophy. Social history included cigarette smoking (1 pack per day for 20 years) and
alcohol intake of 3 to 4 beers daily. Family history was not significant, and he did not remember his
medications. In the emergency department, his vital signs were stable.

His physical examination was remarkable for right-sided facial droop, dysarthria, and right-sided hemiplegia.
The rest of the examination findings were insignificant. His GCS was calculated as 9.

Initial CT angiogram of head and neck reported no acute intracranial findings. The neurology team was
consulted, and intravenous recombinant tissue plasminogen activator (t-PA) was administered along with high-
intensity statin therapy. The patient was admitted to the intensive care unit where his hemodynamics were
monitored for 24 hours and later transferred to the telemetry unit. MRI of the head revealed an acute 1.7-cm
infarct of the left periventricular white matter and posterior left basal ganglia.”

-- Patient Management in the Telemetry/Cardiac Step-Down Unit: A Case-Based Approach by

Muhammad Saad, Manoj Bhandari, Timothy J. Vittorio

Please relate your answers to the above case:

1. Why use tPA? Which type of stroke?

Plasminogen activators (tPA) can be used for acute ischemic strokes of the brain. When there is a blood vessel
endothelium injury, the tissue release tPA into the blood circulation. tPA binds to plasminogen and forms
plasmin. Plasmin digest and removes fibrinogen and fibrin. This help to restore the blood flow to the brain by
breaking down the blood clot.

2. Risk factors for this type of stroke in this patient?

There are several risk factors for this patient. The first is his age. Being over the age 50, makes the patient
more susceptible to strokes and only increases as he ages. Patient also has chronic type II diabetes and chronic
hypertension. Patient also has hyperlipidemia, which means patient has high LDL cholesterol which
contributes to plaque build-up in the arteries. Thrombotic strokes are associated with atherosclerosis and
coagulopathies. It also doesn’t help that the patient smoked a pack of cigarettes for 20 years and drinks beer
daily.

3. S/S support the diagnosis of this stroke?

Motor and sensory deficits include right upper and lower extremity weakness, associated with facial drop and
slurred speech. These are correlated signs and symptoms that the patient is was feeling

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 BL-1 Monday

4. “He denied visual disturbance, headache, chest pain, palpitations, dyspnea, dysphagia, fever,
dizziness, loss of consciousness, bowel or urinary incontinence, or trauma. ” But why was his GCS
still calculated as 9? (Hint: What has been evaluated under the GCS test? What could bring
down the GCS score in this patient? Under this situation, what would be your expectation on his
recovery? )

The GCS is based on a patient’s ability to perform eye movement function, speech and movement of function
of their body. That patients facial drop and slurred speech is the reason why he calculated at 9.

5. Why do you want to know if the patient has “visual disturbance, headache, chest pain,
palpitations, dyspnea, dysphagia, fever, dizziness, loss of consciousness, bowel or urinary
incontinence, or trauma”?

It is very important in order to differentiate the type of stoke the patient had.

6. Based on the following statement “MRI of the head revealed an acute 1.7-cm infarct of the left
periventricular white matter and posterior left basal ganglia.” Which side of the patient's body
would be affected by this statement?

Based on the MRI of the patient’s head, basal ganglia stroke can cause muscle weakness, especially on the left
side of the patient’s body. This stroke will give the patient complication, which is the signs and symptoms of
the patient. The patients slurred speech can also impacted by the damage to the basal ganglia.

7. In the long term what would be the complications of stroke? Please give all reasonable answers
you can think of. Be mindful about ALL organ systems…… (no fixed answers here…..)

Long-term effects of stroke complications and recovery really depends on which part of the brain the stroke
emerged from. Slurred speech, physical disabilities, weakness, paralysis of limbs and decreased motor skills
are often long-term complications after a serious stroke. Personality changes as well as emotional stress and
depression are common. Life-style changes and Physical changes such as weight-can and muscle atrophy are
also associated with stroke because of loss of ability and function of limbs. Memory-loss, vision impairment
and perfection are all things to consider when a patient has had a stroke.

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