Embolic CVA
Patient Presentation:
Patient C.O., an 81 years old female, was cooking dinner when her husband heard the cooking pan drop to the floor. He found her on the floor of the kitchen, conscious, with slurred speech and left sided weakness. He called 911 and EMS brought the patient to an outside hospital. The patient on arrival was alert and oriented to self and place but not to time, and was flaccid on the left upper and lower extremity. The patient has a history of cardiac stents that were placed 3 weeks ago, and says that sometimes her heart "flutters." She is on aspirin at home, and Lipitor®. She complains of no headache and moves the right side 5/5. Her pupils are equal, round and reactive. She is transferred to a stroke center for a stroke work up. A full set of labs are drawn, including INR, 12-lead EKG, chest X-ray and a CT scan with angiogram. Due to her recent cardiac stent placement she is not a candidate for a MRI/MRA or for tPA.
Differential List:
Ischemic stroke, hemorrhagic stroke, transient ischemic attack. Due to the sudden onset of the symptoms, a mass is unlikely; however a hemorrhagic conversion of mass is possible.
Diagnosis
Once the patient was admitted, C.O. received a CT angiogram. The radiologist reported a right middle cerebral artery embolus causing a large right ischemic stroke with a 3mm shift, edema and mass effect.
Treatment
The patient is not a candidate for tPa, so the only treatment at this time for her is supportive treatment. Management of her edema due to the stroke is monitored closely, 3% NaCl is started as a continuous intravenous drip for a goal of a serum sodium 145-150. A right subclavian central line is placed for the 3% to be administered. A Dobhoff tube was placed for feedings and for medication administration as the patients dysarthria did not subside. She failed both a bedside nursing swallow evaluation as well as a formal speech therapy evaluation. Serial CT scans are done to monitor the swelling which after day 3 stabilized. No other interventions were needed. PT/OT came to work with the patient to evaluate further care. During the course of her stay, the patient remained on telemetry monitoring; we found that she has intermittent atrial fibrillation that spontaneously would convert back to sinus rhythm.
Outcome
Patient continued Physical Therapy at an acute rehabilitation facility that can work on the lifestyle changes due to the stroke. Her left side remained weak, but she was able to move gross motor muscles. She however did not regain any dexterity in the left hand. Speech continued to work on her dysarthria, and eventually was cleared to eat a puree diet with thickened liquids. The patient did not require a percutaneous gastric tube.
Case created by Courtney Oliver, 2012.