Home > EB Store > Best Practices For Managing Stroke In The Young Patient: An Update For Hospitalists (Stroke CME)
Best Practices For Managing Stroke In The Young Patient: An Update For Hospitalists (Stroke CME) - $59.00
This issue includes 1 AMA PRA Category 1 CreditsTM
Aleksander Tkach, MD
Vascular Neurologist, Virginia Mason Medical Center, Seattle, WA
Jennifer J. Majersik, MD, MS
Associate Professor of Neurology, University of Utah School of Medicine, Salt Lake City, UT; Vascular Neurologist, Director, Stroke Center at the University of Utah, Salt Lake City, UT
Excerpt From This Issue
A 27-year-old man is brought to the hospital via EMS. He was found unconscious at work, and he was last seen in a normal state 15 minutes prior. He became arousable and oriented on the scene and complained of diplopia. That morning, he had been complaining of nausea, dizziness, headache, and left-sided neck pain. His wife stated that they had been drinking heavily the night before. The physical examination reveals right-gaze horizontal nystagmus, left- and up-gaze vertical nystagmus, left miosis, left arm and left leg ataxia, tongue protrusion to the left, and asymmetric palate elevation to the right only. What diagnosis do these physical findings lead to in such a young patient?
Cervical artery dissection is the most common cause of stroke in the young, followed closely by cardiac sources, and then hypercoagulable states. It is common to misdiagnose brainstem findings as toxic or metabolic findings, and extra attention to the neurological examination is necessary in order to tease these apart. Left-sided neurologic examination findings and left-sided neck pain suggest dissection of the left cervical vertebral artery and a left posterior inferior cerebellar artery territory stroke involving the lateral medulla. The contralateral would be true for right-sided findings. Loss of consciousness and vertical diplopia also suggest emboli to the top of the basilar artery. Patients with occlusion of the top of the basilar artery are at a high risk for locked-in syndrome and death. Urgent imaging of the intracranial and extracranial vessels is important in all young stroke patients, especially those with neck pain suggestive of cervical vertebral artery dissection.