YOUNG STROKE

Dr. Nilanduni De Silva

SHO Medicine- BH Diyathalawa
HISTORY
 HTN , Dyslipidemia for 5 years on regular
follow up
 On Losartan 50mg bd
 Occasional drinker , Non-smoker
 Patient presented following,
a severe headache
L/S body weakness and facial weakness
being unresponsive for 30 mins at home
Aphasia
Dysarthria
 No fits or LOC
 Patient was last seen well before 1 hour of

admission
EXAMINATION
 GCS – E-2
V-3 11/15
M-6
 B/L PERL 2mm
 BP- 130/80 mmHg
 PR – 60 bpm
 DR+ No murmers
 Lungs - Clear
 Neurological Examination –
UL LL
R L R L
Tone NL NL
Power 5/5 0/5 5/5 0/5
Reflexes ++ + ++ +
Planter
Sensory loss on L/S Upper limb
INVESTIGATIONS
 FBC – WBC 15.26
Hb – 17.6
HCT - 46
Plt - 333
 BU – 16
 S.Creatinine – 0.8
 ALT – 17
 AST- 13.2
 INR- 1.08
 CBS - 256
 S.Electrolytes- Na - 140
K - 4.9
 S. Calcium – 9.24
 S.Magnesium – 2.76
 S.Phosphate – 1.5
 ECG – T in II , III , AVF , V4-V6
 UFR - pus cells- 1-2
red cells- 7-8

Urgent NCCT Brain – Right side early malignant MCA

Infarction
Insular ribbon is absent
on R/S.
Grey white differentiation
is decreased on right
MANAGEMENT
 Aspirin 300mg stat
 Atorvastatin 40mg stat
 Supportive care- NG tube,catheterization,IV

N/S 100cc/h
 Contacted Neurosurgical team at PGH Badulla
 Emergency transfer to PGH Badulla for

Decompressive Craniectomy
Decompressive Craniectomy done at
PGH Badulla on 11/06/2023
 Patient was admitted to Neurosurgical ICU and
extubated on the following day
 Patient’s GCS got improved and Medical

management and physiotherapy was continued.

 On post operative Day 3 (14/06/2023) patient died

due to respiratory arrest.

 Post mortem done and COD is as follows,

1a- Intracranial haemorrhage ( hemorrhagic

transformation of the infarction )
1b-Cerebral infarction
11 –Hypertension,Ischaemic heart disease
Did you know ?
Blood supply of MCA

Outer convex brain surface

(lateral surfaces of cerebral
hemisphere and temporal lobe
of the brain) nearly all basal
ganglias and the anterior and
posterior internal capsules
 The term malignant middle cerebral artery (MCA)
infartion,introduced in 1996 was originally
defined as infarction of the entire MCA terittory.
 It is an infarction of atleast 2/3rd of MCA terittory
upward with severe hemispheric stroke syndrome
and progressive deterioration of consciousness
within the first 2 days.
 It causes parenchymal infarction with post
ischemic edema and associated with uncal or
axial herniation,with in 2-4 days of stroke onset.
Clinical presentation
 Contralateral hemiparesis
 Contralateral hemisensory loss
 Hemianopia
 Global Aphasia
 Gaze paralysis
 MCA terittory, is the most affected territory in a
cerebral infarction due to the size of the terittory
and direct flow from ICA to MCA providing easiest
path for thromboembolism
 Treatment includes pharmacological measures to

limit the extent of edema.

 Definitive treatment is Early decompressive

cranioectomy.It reduces brain edema formation by

more than 50% and prevent secondary brain damage
when performed early enough during the 1st 3h after
the event
 Prognosis is poor and mortality is as high as 80%
 Take home message
 Strokes that swell require immediate close
attention
 The main principle is to avoid permanent

brainstem injury from brain tissue shift

 Early decompressive cranioectomy reduces

brain edema formation by more than 50% and

prevent secondary brain damage when
performed early enough.
 Referrences
 National Library of Medicine
 National institute of health and care

excellence
 NICE guidelines 2018 November
 Upto date
 Medscape
THANK YOU