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High-risk of stroke… December 28, 2012

Posted by Andy Jagoda, MD in : Cardiovascular, Neurologic , trackback

A 72-year-old woman with a history of hypertension, diabetes, coronary artery disease, and chronic kidney disease presents shortly after experiencing a 20-minute episode of slurred speech and right facial droop. She denies experiencing similar events in the past, but she does endorse a transient episode of vision loss a week ago, intermittent vertigo, and left-sided weakness last month. On exam, her blood pressure is 178/100 mm Hg, her heart rate is 80 beats per minute and regular, and the ECG shows a sinus rhythm. Her stroke scale is zero, and noncontrast cranial CT scan shows an old small cerebellar infarct. It is Friday evening, and you have no inhouse neurology and no MRI capabilities overnight. The patient attributes her symptoms to stress and states that she has experienced anxiety and palpitations recently. She asks if it is necessary for her to be admitted or whether she can seek follow-up with her primary care physician next week.

How would you handle this patient?

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Comments»

1. Ramy Yakobi - January 1, 2013

Patient probably had TIA. ASA and zocor would be treatment of choice (unless A. Fib on EKG) and admit for Neuro consult, mri and carotid doppler when these become available.

Yakobi

2. Jim - January 1, 2013

Needs admission for risk stratification based on carotid ultrasound, cardiac echo, lipid profile

3. Dr.D.Premkumar - January 1, 2013

In view of hypertension with recurring neurological deficit the patient is suffering from transient ischemic attack.She may proceed to stroke.Hence she requires admission and MRA carotid angiogram followed by medical treatment.She may require anticoagulants and cerebral vasodilators as long term treatment.

4. ashok mishra - January 1, 2013

transient ischemic attack, need admission and further investigation, need aspirin

5. Jessa Ostrom DO - January 1, 2013

With previous and recent TIA symptoms and a current BP as she has I would strongly encourage her to be admitted for improved BP control and neurology consult in the morning.

6. Eak - January 1, 2013

I think that this patient may probably have embolic stroke in nature. She should be admitted for close observation for 5 days, cardiac monitoring and further investigations. The additional investigations I mean are transcranial doppler, carotid duplex ultrasound and echocardiography which are necessary for seeking the origin of emboli. The antiplatelets such as Aspirin and Clopidrogrel should be also started as soon as possible.

7. patrick bruss - January 1, 2013

this patient is high risk with and ABCD score of 6 with a 2-Day Stroke Risk: 8.1%. 7-Day Stroke Risk: 11.7%. 90-Day Stroke Risk: 17.8%. she needs an MRI/MRA, carotid dopplers, TEE, and neurology consult, admit to a neuro step dow or ICU bed with frequent neuro checks and some asprin. the only way i would let her go home is if she signed out AMA and i talked with her family so that they know the risks as well. she is a stroke waiting to happen.

8. Michael Dawson - January 1, 2013

Hi,
I’m not familiar with your website, however I would like to submit an answer. I believe this patient should have a CTA of the arch neck and head. She is not symptomatic from stress and she has had bilateral ischemic symptoms, especially since she does not have a heart arrhythmia. This test can be taken safely and quickly.
Please note I prefer to use my work email not the email from which you sent this information(neurosurg_pa@yahoo.com)
Thanks for offering me the opportunity to partake in this challenge question.

9. CD - January 1, 2013

Because the risk of stroke is highest in the first 48 hours following a transient ischemic, I would explain this to the patient and strongly recommend that she elect admission for further baseline labs and a more thorough neuro evaluation, with MRI/MRA when immediately available. I would also encourage this patient to complete an advanced directive, if she does not already have one—to ensure that someone of sound mind can carry out her medical wishes. regardless of admission, I would collect the following labs: CBC, coagulation survey, full chemistry panel, HA1C, pulse oximetry, urinalysis, blood lipids and an LDH isoenzyme test. Should she have a stroke over the weekend while admitted, I would request immediate transfer to the nearest Level One Trauma Center or nearest facility (less than 3 hours away) that could provide the necessary medical resources to treat this patient and minimize her injury from stroke—-with her permission or her guardian’s permission based on her advanced directive requests.

10. CD - January 1, 2013

Of course a chest X-ray would also be recommended as well.

11. CD - January 1, 2013

Admission to a telemetry unit as well. 🙂

12. dr suresh naidu - January 3, 2013

get her admitted for observation. start aspirin. arrange for neurology review and MRI brain on following Monday.

13. Dr Nik - January 5, 2013

Patient should be admitted. To manage the risk of fatal stroke which include to optimised Blood pressure , cholesterolemia, and stress management . Base line investigations include ecg, cbc, renal profile, LFT, Lipid profile, tiroid function test and for mri soon.

14. rita cohen - January 5, 2013

need addmition for –
1- blood pressure evaluation and control
2- holter monitor to r/o atrial fib
3- duplex carotids and heart echo – if needed tee
4- start antiplatelet aggregant or anticoagilation by need
5- start a mega statin
6- neurologic evaluation and MRI if needed

15. dr. Claudia T. - January 6, 2013

First, I’ll think to HYPERTENSIVE ENCEPHALOPATHY ( she is chronic hypertensive , high BP values and has signs of acute target-organ damage:brain: transient episode of vision loss a week ago, intermittent vertigo, and left-sided weakness last month). I should try to lower the blood pressure by medication; take blood tests, including coagulation survey,urine analysis…keep her in ER until the blood pressure(MAP) is less with 25 %. I can think of course at TIA and PAROXYSMAL ATRIAL FIBRILLATION (she felt: anxiety and palpitations)-(transesophageal echocardiogram needed ). So first a good blood pressure control, and after that think of cardiology and neurology follow-up .

16. mary - January 11, 2013

She should be admitted she has risk for new stroke

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