Stroke Case Study

2/29/2012 | AMRI faculty

A 54-year-old male with an essentially negative past medical history developed visual changes (changing light intensity and transient visualization of small objects) while driving home from his place of employment. He also noted mild numbness and weakening of his left arm and leg. When he arrived at this home, his wife told him it looked as if his left eye was “drooping.” He decided that his day had been stressful and he would benefit from a cocktail. The patient had several cocktails over a 60 minute period and told his wife that “something is really not right.” The wife called 911.

Upon arrival, EMS found a male patient in no apparent distress. His skin color was normal, his vital signs: BP – 128/78; pulse 88 regular; respiratory frequency 13/minute with signs of increased work of breathing. His lungs were clear bilaterally when auscultated. The patient essentially reported the same symptoms as he had to his wife, however, the numbness had significantly worsened, and his speech was somewhat altered.

It was established that the time of initial symptoms earlier in the day was over 6 hours prior. The receiving hospital was notified that the EMS unit had a likely stroke patient. All vital signs, physical findings and information were transmitted to the hospital. While preparing the patient for transport, a reference blood glucose level was obtained with the result of 80 mg/100ml.

Upon arrival to the hospital, the following activities were rapidly initiated:

1. reassessment of patient (symptoms/vital signs, etc.)
2. I.V. access established
3. draw labs (recheck glucose) and obtain 12 lead ECG
4. summon stroke team
5. prepare to transport patient to MRI for brain scan

While undergoing the MRI scan, the patient becomes confused, and worsening left-sided motor dysfunction is observed. The stroke team arrives, evaluates the patient, history and MRI results which showed no sign of hemorrhage. Because of the long delay (>9 hours) between onset of symptoms, fibrinolytic therapy is ruled out. Neurosurgery has been called.

After the case is reviewed by the neurologist and neurosurgeon, it is determined that immediate operation is indicated.

The patient is transported to the operating room and under general anesthesia undergoes a procedure that identifies the intravascular clot. It is evacuated successfully, and the patient is recovering and stable.

Based on the MRI findings, it is determined that the patient likely had hemorrhage from torn carotid plaque that formed the emboli found in the cerebral vessel. Because of the severe delay between symptoms and surgical intervention, long-term negative neurological effects are expected, and will be evaluated as the patient’s recovery progresses.

Important Points For Consideration

The patient’s lack of knowledge regarding the signs of possible stroke, as well as his wife’s slow response led to severe delay in therapy and will probably impact the overall outcome for this patient. Community education should target global knowledge regarding the early signs and symptoms of stroke and the urgent need to access emergency medical care.

Although often a knee-jerk response in emergency situations, supplemental oxygen was not provided to this patient showing NO signs of oxygen deprivation. Hyperoxemia can cause reflex vasoconstriction which could worsen cerebral tissue oxygen delivery.

The patient was taken to a hospital with a stroke team and stroke program. Not all institutions have these capabilities. Triaging patients from the field to the best hospital to provide emergency stroke care has the potential to decrease the time it takes to provide emergency intervention. Once at the receiving hospital, the ED staff should operate in the same rapid manner.

If it does not cause a delay in essential activities such as CAT or MRI scan, a 12 lead ECG should be obtained. Although without symptoms MI and arrhythmias are uncommon, their presence needs to be ruled out in at the least the first 24 hours.

Cardiac monitoring in the acute phase of the stroke patient’s care is essential to monitor for the unexpected onset of atrial fibrillation and/or more serious arrhythmias.

Imaging (CT or MRI) should occur within the first 25 minutes following arrival.

Determination regarding the possibility of fibrinolytic should be made as rapidly as possible. Time is of the essence.

Blood pressure management should target maintaining an acceptable state depending on variables such as the use of fibrinolytic therapy. Significant hypo or hypertension should be avoided.

Because there is evidence that outcomes are potentially worse in patients who are hyperglycemic, monitoring and timely treatment is indicated. Most experts agree that a serum glucose level of 185mg/dL should be addressed.

Hyperthermia should immediately be treated.

Careful airway monitoring and dysphagia screening are essential in preventing secondary pulmonary complications.

Careful observation and if indicated, monitoring of intracranial pressure directly should be undertaken in patients with the potential for such sudden events.