Treating Stroke… June 26, 2012

Posted by Andy Jagoda, MD in: Neurologic , 9 comments

A 64-year-old male presents to the ED with the acute onset of profound right-sided motor weakness and expressive aphasia. The patient has no headache, no history of trauma, and no other problems upon presentation. His only chronic medical problem is hypertension that is well controlled on his medications. His wife witnessed the onset of his symptoms while they were eating dinner 3.5 hours prior to arrival. He has normal vital signs, and a stat CT scan of the head is normal as are his laboratory studies. His deficits have persisted throughout his expedited workup and he is now 4 hours into an acute ischemic stroke (an hour beyond the FDA-approved treatment window for intravenous rt-PA), with a calculated NIHSS score of 16.

What emergent treatment options, if any, do you have for this patient?

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“Troubling headache….” Case Conclusion June 6, 2012

Posted by Andy Jagoda, MD in: Neurologic, Radiology , add a comment

Your second patient was more concerning. Although she had a known primary headache disorder, she described several red-flag features, including nuchal rigidity and pain worst at onset. You recalled a popular headache review paper that highlighted the danger of assuming all headaches in patients with known migraines are benign. You decided to order neuroimaging and, while waiting, moved on to another patient.

Later as you were printing out the discharge paperwork for some other patients, you examined the CT head from your first patient and were surprised to find blood in the basal cisterns. You took a deep breath – thankfully, you did not just refill her prescription.

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