ADVICE TO Mamoon Gee DIAGNOSIS: Right MCA territory Stroke / CVA / haemorrhage, causing profound Left arm and

m and Left leg weakness, power 4-/5 or 3/5 Probable cause is Small vessel haemorrhages secondary to uncontrolled Hypertension, causing small areas of ischaemia Could be from ischaemia secondary to small vessel thrombosis of plaques ?cause could be due to emboli from Carotid or Heart There could be other rarer cause of stroke, including hypercoagulable state like Antiphospholipid syndrome, or inflammatory disease, like vasculitis

INVESTIGATIONS SUGGESTED: Repeat CT Brain---may not be of any benefit, but may show area of hypoattenuation suggestive of ischaemia MRI brain +/- MR Angio,--- to see what areas of brain are ischaemic, what is the arterial supply to those areas, any small aneurysms that could have potential to burst in future due to haemorrhage Carotid US --- not that accurate, so suggest CT Angio CT Angiogram of Carotid and Cerebral vascular tree, to look at arteries supplying the brain and also look at potential source of emboli from Carotid plaque---If there is a Carotid source of emboli, it could be amenable to Carotid Endarterectomy or Carotid Artery Stenting Repeat ECHO (TTE) of heart---to look for cardiac source of embolization May need investigations for rarer causes, such as vasculitis/Hypercoagulable state, like ANA / ANCA / Blood tests for Hypercoagulability

MEDICATIONS SUGGESTED: Control Hypertension---as this is a very important aspect of the disease o ACE inhibitorcurrently on Enalapril o ?Diuretic---currently on Indapamide o ?add on Calcium channel blocker---e.g. Amlodipine or Nifedipine---it will lower BP but also potentially open up small arterioles (vasodilatation) o Have to be careful not to lower BP too much as it will cause further ischaemia of rim of viable brain tissue surrounding the ischaemic area Need to lower lipids and stabilise plaques o Check Lipid profile o Even if lipid profile normal, commence a Statin, e.g. Atorvastatin, as many trials have suggested good plaque stabilization by Statins in people whose cholesterol is normal Need to control Hyperglycaemiaas it can potentially cause further damage to ischaemia area and contribute to further CVAs in future o Metformin o Gliclazide o If the above combination is not working, consider newer agents like Januvia (Sitagliptin)

Anticoagulationto keep blood thin and act against thrombosis o Aspirin--- confirm stroke is ischaemic first, o May benefit from Aspirin +Dipyridimole (Asasantin SR)

FURTHER PLAN: Neurologist consultation May need Vascular Surgeon Consultation, if there is Carotid Arterial disease Physiotherapyfor hands, arms and legs, Dua Help in mobilization and activities of daily living