Case of 50 year old housewife with left sided upper and lower limb weakness with deviation of mouth to right side

 This is the case I was given.  ( Hall ticket number:- 1601006118 )

A 50 year old housewife came to the casuality in the afternoon with presenting complaints of

1) Sudden onset Weakness in her left upper and lower limbs since 3 days

2) deviation of the angle of mouth to the right side since 3 days

History of Present Illness:-

Patient was apparently asymptomatic 3 days ago when at around 8:30 am in the morning while she was doing her daily chores she suddenly felt weakness in her left side of the body and couldnt move her left upper and lower limbs. The episode was sudden in onset and the evolution of weakness was completed within 6 hours. At the beginning of the attack , patient complained of dizziness followed by a fall onto her hips. She did not have any loss of consciousness before or after the fall. The patient's attendant observed that the patient had deviation of mouth to right side and that her speech was slurred and on giving her water to drink , he noticed that there was drooling of saliva from the left side of mouth.

Patient had no H/O fever, vomiting, convulsions, headache, bowel or bladder disturbances, behaviourial abnormailities

No H/O  loss of smell/alteration of smell

No H/O loss of vision, diplopia

No H/O hearing loss

No H/O nasal regurgitation

Patient also had no complaints of tingling, numbness. She was able to differentiate warm and cold water while she was having her bath.

No H/O chest pain, palpitation, shortness of breath

Past History:-

Patient had hysterectomy 6 years ago for fibroid uterus, during the hospital stay for surgery patient was diagnosed with Hypertension and Diabetes mellitus for which she given Tablet Telmisartan 40mg OD, Tablet Glimepiride 1mg OD.

No H/O CVA, CAD, Tuberculosis and Epilepsy

Family History:-

No history of similar complaints in the family.

Personal History:-

Patient gave a history of consumption of alcohol for the past 15 years. Diet - Mixed, Sleep - adequate, Bowel movements and bladder habits normal.

Drug history:-

Patient is on Tab. Telmisartan 40mg OD and Tab. Glimepiride 1mg OD since last 6 years. No other drug use or drug allergies.

Provisional Diagnosis:-

50 year old housewife with left sided hemiplegia with left sided facial palsy probably due to a cerebrovascular accident ( ischemic stroke due to a cerebral thrombus?) with H/O DM,HTN..

General Examination:-

Patient is conscious, coherent and cooperative, afebrile and well built.

Pulse-70 bpm
BP- 110/70 mm hg right upper limb supine position
RR-14 cpm
No pallor, icterus, clubbing, koilonychia, lymphadenopathy and edema

CNS EXAMINATION:-

1. HIGHER MENTAL FUNCTIONS-
    within normal limit and intact

2. CRANAL NERVES-
    7TH nerve- upper half-spared
                       frowning present on both sides
                       symmetry of blinking present
                       lower half-
                      Obliteration of nasolabial folds on left side
                      angle of mouth deviated to the right side
                      dribbling of saliva on left side; blowing and       whistling absent. 

   all other cranial nerves - intact.

3.MOTOR FUNCTIONS:-
                                                                                   RIGHT                           LEFT

BULK :                                                                 NORMAL                         NORMAL

TONE :                                        UL                            N                      Normal
                                                     LL                            N                      Normal 

POWER :                                    UL                            5                                     0
                                                    LL                            5                                      3

CO-ORDINATION :                  UL                          INTACT                      CANT BE ELICITED
                                                    LL                          INTACT                      CANT BE ELICITED

INVOLUNTARY MOVEMENTS- Absent

SUPERFICIAL REFLEXES :  

Corneal reflex- present on both sides  

Conjunctival reflex- present on both sides
                              ABDOMINAL RELFEXES        PRESENT                    PRESENT

                                                    PLANTAR             FLEXOR                      EXTENSOR

 DEEP TENDON REFLEXES  :           
                                                  BICEPS                       2+                               3+
                                                  TRICEPS                     2+                               3+
                                                  SUPINATOR               2+                               
                                                  KNEE                          2+                                3+
                                                  ANKLE                        -                                   -

4. SENSORY FUNCTIONS-
    No loss of superficial sensations like - pain, touch, temperature
    No loss of deep sensations like - vibration, joint sense, position
    No loss of cortical sensations.

5. CEREBELLAR FUNCTIONS - 
    Intact
    Patient has no titubations
                      no scanning of speech

6. ANS - 
    Patient has no postural hypotension.

DIAGNOSIS :
A 50 yr old female with LEFT SIDED HEMIPLEGIA WITH LEFT SIDED UMN TYPE FACIAL PALSY (COMPLETE HEMIPLEGIA) probably due to an ISCHEMIC STROKE caused by a cerebral THROMBUS in the MCA territory involving RIGHT SIDED INTERNAL CAPSULE with H/O HTN, DM.

INVESTIGATIONS :

CT BRAIN-

ECG-

2D- ECHO :

X-RAY  HIP :

Examination Videos:-

Drugs:-

Treatment:- 

Comparative Effectiveness of Aspirin and Clopidogrel Versus Aspirin in Acute Minor Stroke or Transient Ischemic Attack

Kim, Joon-Tae et al. “Comparative Effectiveness of Aspirin and Clopidogrel Versus Aspirin in Acute Minor Stroke or Transient Ischemic Attack.” Stroke, STROKEAHA118022691. 7 Dec. 2018, doi:10.1161/STROKEAHA.118.022691

PICO format:-

Patient:-  5590 patients met the eligibility criteria of including (1) acute minor ischemic stroke defined as National Institutes of Health Stroke Scale score ≤3 or lesion positive transient ischemic attack within 24 hours of onset and (2) noncardioembolic stroke mechanism

Intervention/Comparison:- 3695 patients received Aspirin and 1895 patients received  Aspirin + Clopidogrel

Outcome:-The primary outcome was major vascular events, defined as the composite of all stroke (ischemic and hemorrhagic), myocardial infarction (MI), and vascular death at up to 3 months after index stroke. Secondary outcomes were the following individual events: (1) all stroke (ischemic and hemorrhagic), (2) MI, and (3) vascular death

In unadjusted analysis, the rate of major vascular events at 3 months was lower in the clopidogrel-aspirin versus aspirin groups (9.9% versus 12.2%, P=0.009; Table 2). The secondary end point of all stroke also occurred less often in patients receiving clopidogrel-aspirin than those receiving aspirin (9.1% versus 11.5%, P=0.005). However, for the events of MI and vascular death, there were no differences between the clopidogrel-aspirin and aspirin groups.

Conclusion:- In this study, among patients with acute, minor, noncardioembolic ischemic stroke who were treated with clopidogrel-aspirin or aspirin, initial dual antiplatelet therapy with aspirin and clopidogrel was associated with fewer major vascular events, and fewer recurrent strokes, during the first 3 months after stroke, both in unadjusted analysis and in adjusted, propensity-weighted analysis. The benefit was greatest for patients who were older, had non-SVO stroke mechanism, and whose index stroke had occurred while on antiplatelet therapy, with benefit not observed for patients with small vessel disease subtype.

Other Articles:-

N Engl J Med 2018; 379:215-225

DOI: 10.1056/NEJMoa1800410Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA

List of authors.

Role of Atorvastatin in Acute Ischaemic Stroke:-

High-Dose Atorvastatin after Stroke or Transient Ischemic Attack DOI: 10.1056/NEJMoa061894

This prospective, randomized, placebo-controlled trial demonstrated that treatment with 80 mg of atorvastatin per day reduced the risk of subsequent stroke in patients without known coronary heart disease and with LDL cholesterol levels of 100 to 190 mg per deciliter who had had a recent stroke or TIA.