CASE REPORT: TRANSIENT ISCHEMIC STROKE IN A 72-YEAR-OLD WOMAN WITH UNDERLYING
DIABETES MELLITUS TYPE 2 AND HYPERTENSIVE CARDIOVASCULAR DISEASE
Norodin E. Tumagantang II
Medical Clerk
Davao Doctors Hospital – Department of Internal Medicine
INTRODUCTION____________________________
According to American Heart Association,
transient ischemic attack is characterized as
brief episodes of neurological dysfunction due to focal
cerebral ischemia that is not associated with
permanent cerebral infarction. The previous definition
of transient ischemic attack requires that all
neurologic signs and symptoms resolve within 24 h
without evidence of brain infarction on brain imaging.
However, this definition is no longer accepted since
this definition is too broad and some cases of
transient ischemic attack shows imaging
abnormalities on MRI. Risk factors for transient
ischemic attack include diabetes, hypertension, old
age, smoking, obesity, alcoholism, and unhealthy
diet; with hypertension being the most important risk
factor. This medical emergency needs urgent
evaluation with imaging and laboratory studies to
lessen the risk of subsequent strokes.
CASE_____________________________________
This is a case of 72-year-old female who
came in to the emergency department of the Davao
Doctors Hospital due to right sided lower extremity
weakness. A day prior to the admission, the patient
was apparently well. She did not feel any headache,
dizziness, nausea and vomiting. She just stayed at
home.
Less than 6 hours prior to admission, around
12:05 am patient was in bed when she noted sudden
right sided back pain with as pain scale of 10/10
radiating to the right arm. This was also associated
with inability to lift her right leg. However, no other
associated symptoms noted such as headache, facial
asymmetry, slurring of speech, nausea or vomiting.
The symptom only lasted for less than 10 minutes.
Due to the alarming syptoms, she was then brought
to San Pedro Hospital where her blood pressure at
that time was at 189/97 mmHg. No medications given.
Due to nonavailability of room, she was advised for
transfer and eventually, she was brought to the Davao
Doctors Hospital and was admitted.
Her past medical history is significant of
hypertension for 10 years with a usual blood pressure
of 140-160/70-100 mmHg. She was prescribed with
unrecalled maintenance medication. However she
was noncompliant. She also had cataract surgery on
both eyes around 2010 at the Souther Philippines
Medical Center. No medical illness such as asthma
and diabetes and no history of previous myocardial
infraction or stroke. She does not have any food and
drug allergies and she was vaccinated with Pfizer 2
doses. The patient claimed of taking herbal
medication (MG Panyawan) for 2 years.
Her family history revealed that her father
was hypertensive and had history of stroke. In
addition, her daughter has history pulmonary
tuberculosis in 1986 and his grandson also had
pulmonary tuberculosis in 2018 which were both
completed the 6 months treatment. The patient
denied family history diabestes mellitus, bronchial
asthma or malignancy.
She is a housewife. A previous smoker with
22.5 pack years and previous alcoholic beverage
drinker.
The review of systems was significant of
polyuria and polydpsia. No fever, chronic cough,
hemoptysis, night sweats, weight loss, polyphagia,
numbness of extremities, anorexia, agnosia and
palpitations. At the ward, the patient denied
headache, dizziness, shortness of breath, chest pain,
and abdominal pain.
Upon physical examination, the patient was
noted to be awake, comfortable, sitting and not in
distress. She is afebrile with normal heart rate,
respiratory rate, and O2 saturation of 99% a room air.
However, her blood pressure is elevated at 160/80
mmHg. The patien’s BMI was 24 and can be
classified as Overweight based on Asia Pacific
Classification. Complete neurologic exam was carried
out to this patient and she was well oriented with
person, time, and place and followed commands; her
Glasgow Coma Scale was 15. Cranial nerves are all
intact, 5/5 motor strength on all extremities and no
sensory deficits on extremities. Babinski sign was
also negative and no dysmetria and
dysdiadochokinesia were noted. Table 1 shows the
complete physical examination done on this patient.
SALIENT FEATURES________________________
• 72-year-old, female
• Right sided back pain, PS 10/10, radiating to
the right arm
• Inability to lift right leg
• No headache, slurring of speeach or facial
asymmetry
 • Hypertensive (160/80 mmHg) Table 1. Complete Blood Count upon admission
• Overweight Result Normal Values
• No tachycardia, no tachypnea Hemoglobin 141 g/L (H) 120-140
• GCS 15 Hematocrit 0.39% 0.37-0.45
• Intact cranial nerves RBC 4.36x10^12/L (L) 4.5-5.0
• No sensory deficit WBC 10.85x10^9/L (H) 5-10
• Negative babinski Neutrophils 0.66 (H) 0.55-0.65
• No dysmetria Lymphocytes 0.29 (L) 0.35-0.45
• No dysdiadochokinesia Eosinophils 0.01 (L) 0.02-0.04
Basophils 0.01 0-0.02
ADMITTING IMPRESSION________________
1. To consider Transient Ischemic Attack Platelets 127X10^9/L (L) 150-400
2. Hypertensive Cardiovascular Disease
3. Diabetes Mellitus Type 2 Table 2. Other laboratory tests requested for the
4. Pulmonary Tuberculosis – Suspect patient upon admission
Result Normal Values
The impressions above were made based on HbA1c 8.20% (H) 120-140
the history and physical examination of the patient. Creatinine 110.2 (H) 50.4-98.1
Transient ischemic attack was considered due to the EGFR 43 4.5-5.0
brief onset unilateral weakness that lasted for less ALT 55 5-10
than 10 minutes. Unilateral paresis is the most
NA 137 mmol/L 136-145
common symptom in patients with transient ischemic
attacl. Hypertensive cardiovascular disease was also K 3.70 mmol/L 3.5-5.1
added since the patient already had this for 10 years. Ca 2.35 mmol/L 2.1—2.55
The Diabetes Mellitus and Pulmonary Tuberculosis Mg 0.79 mmol/L 0.7 - 1
were also included and were further investigated.
Other diagnostic Radiologic studies such as
DIAGNOSTICS TESTS___________________ chest x-ray and head CT scan were done on this
Upon admission, diagnostics tests were patient and the result are presented below (Figure 1
performed on this patient to establish the origin of the and 2).
symptoms. Presented below were the results of the
laboratory tests and imaging studies performed on
this patient on the day of admission. The complete
blood count showed an slight deviation in hemoglobin
level and red blood cell count. However, significant
increase in white blood cell count and neutrophil
counts were noted with decrease in lypmphocytes
count. In patients who had an acute onsent of
ischemia, neutrophils and lymphocytes value are
deviated due to the ongoing inflammation (Wang,
2021). In addition, the neutrophil-to-lymphocyte ration
can also be a prognostic marker in patents with acute
ischemic stroke. The decrease in platelet of the
patient may be due to the impairement of liver
functions and this needs to be further investigated.
Result of the whole abdomen ultrasound will be
discussed on the next part.
Table 2 shows the rest of the laboratory tests Figure 1. Chest X-ray image upon admission
done for this patient, HbA1c level was significantly
increased (8.20%) and also the creatinine level which The chest x-ray showed normal heart size
can also signify compromise in the kidney functions. and calcifications in the aorta. In addition,
These laboratory test results were further investigated reticulonodular opacities and round lucencies were
and the results will be discussed on the next part. also noted in both upper lobe with irregular pleuro-
apical thickening. The impression were suggestive of
chronic inflammatory lung disease compatible with
PTB, bilateral pleuro-apical thickening, aortic
atherosclerosis and degenerative joint disease.
Figure 2 shows the head CT scan of the
patient which was performed less than 6 hours prior
to admission. Findings were compatible with chronic
lacunar infracts in the right corona radiata and
lentiform nucleus. Cavum septum pellucidum and
atherosclerosis were noted. In adiition, cerebral
atrophy which is not unusual for the patient’s age was
also seen.
Figure 2. Head CT image upon admission
FINAL IMPRESSION_________________________
1. Transient Ichemic Attack
2. Hypertensive Cardiovascular Disease
3. Diabetes Mellitus Type 2
4. Pulmonary Tuberculosis – Suspect
PLAN_____________________________________
The patient was given intravenous fluid in the
form of PNSS at 80 cc/hr. Her diet was advised to be
low salt, low fat, and diabetic diet. Capillary Blood
Glucose were also performed three times a day and
at bedtime. Additional laboratory tests that were
requested include lipid profile and fasting blood
glucose and sputum AFB testing.
The patient started her Insulin Glargine
(Toujeo) 12 units SQ OD on that day of admission
together with Insulin Glulisine (Apidra) 4 units SQ TID
premeals.
For the medication reconciliation,
Atorvastatin 80mg 1 tab PO OD at HS, Clopidogrel
75mg 1 tab PO OD, Aspirin 80mg tab, 1 tab PO OD,
Pantoprazole 40mg 1 tab PO OD pre breakfast,
Losartan 100mg 1 tablet OD were included.
COURSE IN THE WARD______________________
Day 1
During the day 1 of hospital stay of the
hospital stay of the patient, she had no any subjective
complaints. The vital signs were all stable except for
an increased in blood pressure (140/80 mmHg).
Capillary blood glucose result at 5pm and 9pm were
348 and 240, respectively. The physical examinations
were unremarkable. Complete neurologic
examinations were also made once again and it
revealed a GCS of 15, the patient is oriented to
person, time and place and followed commands. The
cranial nerves were all intact. Motor strength were 5/5
on all extremities and no sensory decifits noted.
The result of the lipid profile, fasting blood
sugar, and blood uric acid of the patient is presented
on Table 3.
Table 3. Total Cholesterol, Triglycerides, Glucose
(FBS), Blood Uric Acid level on the Hospital Day 1
Result Normal
Values
Total 132.69 mg/dL 0-200
Cholesterol
Triglycerides 111.50 mg/dL <150
Glucose, FBS 123.82 mg/dL 80-116
(H)
Blood Uric Acid 6.22 mg/dL (H) 2.6-6.0
The glucose level of the patient is significantly
increased and this confirms the diagnosis of the
Diabetes Mellitus Type 2. Her blood uric acid level
was slightly elevated.
Electrocardiogram was done also to the
patient the result showed a normal sinus rhythm.
Utrasound of the abdomen was also
performed on this patient and its showed a hepatic
cirrhosis, renal cyst on the right meddle pole, and
renal cortical calcification on the left superior pole.
This imaging should be correlated on the other
laboratory results.
The decrease in the platelet shown in the
complete blood count of the patient was probably due
to the hepatic damage that compromises the function
of the liver. According Mitchell et al, 2016,
thrombocytopenia is the most common hematological
abnormality found in patients with liver disease. The
thmbocytopenia is the result of the decrease
production of the thrombopioetin (TPO) by the liver
due to the cirrhosis (Hayashi et. al, 2014) The
increase in creatinine shown in the complete blood
count may be due to the compromised function of the
kidneys which showed renal cortical calcification and
cysts.
The patient failed to submit a sample of her
sputum the sputum AFB and sputum gene xpert were
not carried out

Day 2
On the second day of admission, the patient
did not show any signs of recurrence of the neurologic
symptoms. Her vital signs were stable. Thus the
patient was discharged. He was also given take home
medications which are listed below.
Table 4. Take home medications given to the patient
upon discharged.
1. Metformin (Glucophage tab 500 mg)
2. Linagliptin (Trajenta tabl 5 mg)
3. Atorvastatin Ca (Avamax tab 40 mg)
4. Aspirin (Aspilets tab 80 mg)
5. Clopidogrel bisulfate (Plavix tab 75 mg)
6. Amlodipine besylate (Amvasc-BE tab 5mg)
DISCUSSIONS_____________________________
Transient Ischemic Attack
Definition and Etiology
Originally, the transient ischemic attack is
defined as brief focal cerebral ischemic event with
symptoms lasting <24 hours with episodes lasting
less than 1 hour. However, the AHA/ASA released a
revised definition as this old definition was too broad
and several studies have shown that up to 50% of
classically defined TIAs showed brain injury on
magnetic resonance imaging (MRI). The newer
definition of transient ichemic attack is "a transient
episode of neurologic dysfunction caused by focal
brain, spinal cord or retinal ischemia without acute
infarction." The transient loss of cerebral blood flow
can be due to small artery occlussion, cardio aortic
embolism or large vessel atherosclerosis (AHA/ASA,
2009).
Epidemiolgy
In the United States, the incidence of TIA in
the has been estimated to be ≈200 000 to 500 000
per year, the population prevalence is 2.3% which is
approximately 5 millions individuals. The incidence of
transient ischemic attack increases dramatically
increases regardless of race and gender.
Furthermore, transient ischemic attack were proved
to be more prevalent in Mexican Americans
compared with non-Hispanic whites at younger ages
(45 to 59 years) but not at older ages (AHA/ASA,
2009).
Risk factors
Risk factors for all transient ischemic attack
include hypertension, diabetes, old age, obesity,
cigarette smoking, alcoholic beverage drinking, and
unhealthy lifestyle. Among those aforementioned,
hypertension is the most important risk factors for an
individual and for the population (AHA/ASA, 2009,
Navis et al, 2019).
Based on the history of the patient, she have
a long standing hypertension for 10 years, as
previouslt mentioned hypertension is the most
important risk factor. In addition, her age, diabetes,
history of smoking and alcoholism had a major
contribution to the transient ischemic attack.
Pathophysiology
The pathophysiology of transient ischemic
attack varies depdending on the underlying cause. In
patients with small vessel ischemic disease, transient
ischemic attack is the result of either lipohyalinosis or
small vessel arteriolosclerosis. In cardio aortic
embolism, the thrombus that is formed in the
fibrillationg atrium or atrial appendage travels to the
brain and causes occlusion of cerebral artery. Finally,
in patients with large artery atherothrombosis, the
transient ischemic attack is caused by either
intracranial or extracranial atherothrombosis. The
sudden onset of the neurologic symptoms is due to
the a lack of blood flow distal to the site of arterial
stenosis or an artery to artery embolism.
Approach to Patient with Transient Ischemic Attack
Commonly, patient with transient ischemic
attack have brecovered with their symptoms by the
time they arrived in the emergency room. When the
patient present with symptoms suggestive of cerebral
ischemia, a comprehensive history should be carried
out to establish the onset, duration, timing, complete
neurological symptoms, associated symptoms, and
alleaviating or aggravating factors. Emphasis should
also be given to the presence or absence of
nonspecific symptoms common in TIA mimics. The
physician should also try to identify any of risk factors
associated with transient ischemic attack. Family
members who witnessed the the event can be of great
help in describing symptoms that the patient may
miss. Symptoms of transient ischemic attack has brief
onsent and include a neurologic deficit or loss of
function.
Table 5 shows the clinical symptoms of
transient ischemic attack versus its mimics. Unilateral
paresis is the most common symptoms in patients
with transient ischemic attack and also in transient
ischemic attack mimics.
Table 5. Clinical symptoms and its percentage in
transient ischemic attack and its mimics Table 6. The ABCD2 Score
Clinical Symptoms % of TIA % of TIA Clinical Factor Score
mimics A: Age >/= 60 years old 1
Unilateral paresis 58 29.1 B: SBP of >140 mmHg or DBP of >90 1
Memory loss 2 to 12 18 to 26 mmHg
C: Clinical symptoms
Headache 2 to 36 14.6 to 23
Unilateral paresis 2
Blurred vision 5.2 21.8 Speech deficit
Dysarthria 20.6 12.7 D: Duration
Hemianopia 3.6 3.6 >60 min 2
Transient monocular 6 0 10-59 min 1
blindness D: Diabetes mellitus 1
Diplopia 4.8 0
The sum of all the category is the ABCD2
Physical examination should be performed to score. An ABCD2 score of 0 or 1 has 0% 2-day risk
be able to identify the presence of motor weakness of stroke, 1.3% for scores 2 or 3, 4.1% for 4 or 5, and
and speech deficits as these two are highly 8.1% for 6 or 7.
suggestive of transient ischemic attack. Cranial nerve For the patient, her ABCD2 score was 6 so
examination can identify important findings such as her 2 day risk of stroke is 8.1% which is higher.
mocular blindness and diplopia. Motor strength on all
extremities should also be assessed. Presence of Management
sensory deficit should also be noted. Cardiac The main goal of of treatment of transient
examination and carotid auscultation for a carotid ischemic attack is to decrease the risk of subsequent
bruit are very important in patients with transient stroke. Early treatment after a transient ischemic
ischemi attack. stroke can significantly reduce the risk of early stroke.
Diagnostic evaluations are carried out to In addition, management of transient ischemic attack
prove the vascular origin of the symptoms, to should focus on treating underlying etiologies.
determime the underlying vascular mechanism, to In a large Chinese (CHANCE trial) and the
exclude other non-ischemic origin, and to identify multinational POINTE trail, they found out that aspirin
prognostic outcome categories. Based on the and clopidogrel was found to prevent stroke following
Guidelines of AHA/ASA, neuroimaging wihtin 24 transient ischemic attack better than aspirin alone.
hours of symptom onset where MRI and diffusion- Failure to respond to the combination of aspirin and
weighted MR imaging are preffered. Hoewever, if clopidogrel is significantly associated to
these wo are not available, head CT scan is the polymorphism in CYP2C19 that leads to poor
alternative. Cardiac assessment should be carried out metabolism of clopidogrel into its active form. This
with ecectrocardiogram (ECG), electrocardiography mutation is common, particularly in Asians.
(2D-echo), and CT angiography. Routine blood tests
such as complete blood count (cbc), FBS, lipid profile, REVIEW OF MEDICATIONS USED______
PT/INR, liver function tests, kidney function tests 1. Metformin
should also be performed. Drug class
2. Linagliptin
Risk stratification 3. Atorvastatin
The risk of stroke after a TIA is approximately 4. Aspirin
10-15% in the first 3 months, with most events 5. Clopidogrel bisulfate
occurring in the first 2 days. This risk can be directly 6. Amlodipine besylate
estimated using the well-validated ABCD2 score. The
ABCD2 score is widely used as a scoring tool to REFERENCE
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