A 63 Year Old Man Presents With Symptoms Of Stroke

A 63 year-old hypertensive man is brought to the emergency department with onset of right face, arm, and hand paralysis, as well as difficulty in communication. Rapid diagnostic testing using MRI revealed an ischemic infarct in the left middle cerebral artery.

The patient was diagnosed as a case of stroke. He was immediately given tissue plasminogen activator (TPA). After the stroke, he was treated with aspirin, antihypertensives, and cholesterol-lowering medication. He recovered 80% of his neurologic deficit over the next 3 months.

Case Discussion:
Stroke Or Cerebral Vascular Accidents: 
Cerebral vascular accidents or strokes are common, especially in older populations. Most strokes are ischemic (66%)  or hemorrhagic(10%).

Risk factors include :

• hypertension, 
• smoking, 
• diabetes mellitus, 
• atrial fibrillation.
• Obesity
• Black ethnicity.
• Older age 

Pathophysiology: 

1. Ischemic stroke occur when atherosclerosis progresses to a plaque,which ruptures acutely. Each step of this process is mediated by inflammation. 

2. Hemorrhagic stroke occur when vessels bleed into the brain, usually as the result of elevated blood pressure.

3. Other known causes of CVAs include : 

• inflammatory disorders (giant cell arteritis, systemic lupus erythematosus [SLE], polyarteritis nodosa, granulomatous angiitis, syphilis, and AIDS), 
• fibromuscular dysplasia, 
• drugs (cocaine, amphetamines, and heroin), 
• hematologic disorders (thrombocytopenia, polycythemia, and sickle cell),
• hypercoagulable states.

Clinical features: Acute onset of neurologic signs and symptoms are based on the site of the Cerebrovascular accident. 

1. Middle cerebral artery is the most common ischemic site:

~ Superior branch occlusion causes contralateral hemiparesis and sensory deficit in face, hand, and arm, and an expressive aphasia if the lesion is in the dominant hemisphere.

~ Inferior branch occlusion causes a homonymous hemianopia, impairment of contralateral graphesthesia and stereognosis, anosognosia and neglect of the contralateral side, and a receptive aphasia if the lesion is in the dominant hemisphere.

2. Internal carotid artery occlusion causes contralateral hemiplegia, hemisensory deficit, and homonymous hemianopia; aphasia is also present with dominant hemisphere involvement.

3. Posterior cerebral artery occlusion causes a homonymous hemianopia affecting the contralateral visual field.

Diagnosis: The diagnosis is clinical when there is history of risk factors along with typical neurologic deficits. Some laboratory workup may be done when the cause of stroke is not clear. These tests include: 

• Complete blood count (CBC) for thrombocytosis or polycythemia.
• Erythrocyte sedimentation rate (ESR) for diseases such as giant cell arteritis or SLE.
• Testing for syphilis using a treponemal enzyme immunoassay (EIA), with positive results confirmed by a nontreponemal test (Venereal Disease Research Laboratory [VDRL]).
• Serum glucose to eliminate hypoglycemia as the cause of the neurologic symptoms.

Imaging Studies:  CT or MRI can distinguish ischemic from hemorrhagic and localize the lesion.

Differential Diagnosis: other causes of acute neurological dysfunction include:

• Transient Ischemic attack
• Multiple sclerosis
• Brain mass or tumor
• Migraine 
• Hypoglycemia.

Management : depends upon the underlying cause;

1. Ischemic Stroke: needs quick restoring of blood flow to the affected portion of brain. Treatment with drugs that break up the clot should be given immediately within 3 hrs of beginning of the symptoms. The quicker the treatment is started the better is the outcome. 

• Aspirin is the drug that is given immediately in the emergency room to help prevent the risk of another stroke as well as it helps in preventing new clots to form.
• Some patients benefit form an injection of tissue plasminogen activator (TPA), it helps in restoring blood flow by dissolving the blood clot that caused the stroke. 

2. Hemorrhagic Stroke: the treatment should focus on controlling the bleeding and reducing the pressure in the brain. 

Rehabilitation After Recovery From Stroke: After emergency treatment , it is important to help the patient recover and regain the strength and function as much as possible. Good and regular physical therapy helps in regaining most of the function.