History of Presenting Complaint
Mrs A is a 66-year-old lady with a history of stroke and residual neurological deficit. She has left sided ischaemic cerebral stroke in 2002, after which she had a couple of minor strokes and TIAs.
The proper history of her initial symptoms could not be properly carried out primarily due to communication difficulties occurred as a result of this devastating stroke. However, her notes state that she had an ischaemic stroke confirmed by CT scan and subsequently thrombolysed. The initial symptoms constitute a classical picture of the diagnosis. She developed sudden weakness over the right side of the body (right hemiperaesis) and expressive dysphasia. At the time, her right limbs were floppy and without power. Currently she presents a picture of an old cerebral infarct with rigidity and spasticity over the right side of the body. The lower limb improved a little bit as she could move it, but tone was definitely increased.
She is well cared by both the primary and secondary multidisciplinary teams. Though she is wheel chair bound, she gets help from her daughter who lives nearby her house.
Mrs A has various risk factors that increased her chances of having stroke. These include hypertension, seizures, DVT, etc.
There is no history of diabetes or asthma; she does have stable angina.
There is no history of diarrhoea or vomiting or weight loss.
Past Medical History
Drug History
Family History
Social History
On Examination
General Observations
Renal
CVS
Respiratory
Neurological
Summary of Mrs A's Problems
Mrs A has devastating stroke which rendered her paralysed for life. She is managing well though communication is still the main problem. Sometimes, she feels depressed which is quite understandable given her condition. We need to focus on her mobility issues as she may get infections or sore pressure by prolonged sitting. At the moment she is not getting enough sleep and sleeps in a couch in front of TV. She was persuaded by her daughter and the GP to get proper sleep and she agrees to it.
Management Plan
At present, there was no need to run any particular blood test apart from checking her BP. The general management of stroke has been discussed below in reflective commentary.
Reflective Commentary
Stroke results from ischaemic infarction or bleeding into part of the brain. It is manifested by rapid onset of focal CNS signs and symptoms which last for more than 24hrs. The incidence of stroke rises with increasing age. The major causes are: (1,2)
Some rare causes include:
Risk factors
These are the recognised risk factors:
Signs (2)
Stroke can typically present as a sudden onset or step-wise development over hours or days. Focal signs represents and can relate to the distribution of the affected artery, but collateral supplies can sometimes make the distinction difficult.
Investigations (1,2)
Early and quick investigation to confirm diagnosis and avoid further strokes is paramount, but consideration must be given whether results will affect treatment and subsequent management.
Stroke: Management and Prevention
Imaging (2,3)
Urgent CT/MRI should be carried out in all stroke patients and especially if:
Discussion with the patient and the relatives is very important at every step of treatment and decision and improves outcome. Stroke patients should be managed in specialised stroke units with specialist physician and nurses
Acute Antiplatelet measures: Acute aspirin 300mg/24hr for 2 weeks and then 75mg/day should be started unless CNS bleed is highly suspicious. If ischaemia is confirmed by CT scan, NICE advices that dipyridamole should be added. If patient is aspirin-intolerant, give proton pump inhibitor; if they have hypersensitivity, give clopidogrel instead. (3)
Primary Prevention: Controlling the risk factors such as smoking, BP, DM, lipids, and possibly folate significantly reduce the risk of having further stroke. Regular exercise also helps; this also improves glucose tolerance and increases the level of HDL. Help should be given to quit smoking through smoking cessation counselling and patches, etc. Even switching to pipes may attain some benefit. Life long anticoagulants should be used if rheumatic fever or prosthetic heart valve disease of the left side is present. Warfarin in chronic AF should be considered. TIAs also increase the risk of having stroke therefore their further prevention is essential. (1,2)
Secondary Prevention: again controlling the risk factors prevent having further episodes. A number of large studies have suggested that substantial benefits can be achieved by lowering the BP and lipids even if they are not raised. Using aspirin combined with BD MR dipyridamole or use of clopidogrel instead of aspirin offers added benefits. (2)
The future of ischaemic Stroke: Trials have suggested rapid assessment of 'brain attacks' and subsequent thrombolysis with tPA within 3h of onset of symptoms. This decreases poor outcomes by 12%. However, major contraindications are: (1,2,3)
Rehabilitation after Stroke (2,3)
In addition to general principles of any chronic illness, the stroke patients must be screened for the following. There are a number of scales to gauge the rehab, handicap or disabilities. Barthel's index is the widely used one to assess the degree of independence form any help.
Screen for depression: According to one figure, 33% are depressed, and untreated. This badly affects the overall mortality, and can be avoided by taking proper measures. This is particularly important for Mrs A since she feels depressed and anxious at times. Her care around this faculty would improve her prognosis.
Tests: there are various testing techniques to employ to gauge the return of functioning if at all. These functions include apraxia, spatial ability, agnosia, etc.
Neurorehabilitation: This constitutes a functional approach to build on what a patient can do with speech and physiotherapy. Encouragement by making it entertaining for patients is equally important. This can be achieved with activities such as swimming, video gaming, etc. The object is to improve cerebral reorganisation.
References
