CVA CASE

PRESENTATION
MAHIMA
BMCRI
Patient Details
◦ Name: Mr XYZ
◦ Age: 48 Years
◦ Gender: Male
◦ Occupation: Coolie
◦ Address: Jayanagar, Bangalore
◦ Education: 10th Std
◦ Socio-economic status: Upper Lower according to Modified Kuppuswamy classification
◦ Informant: wife
◦ Handedness: Right
◦ Date of Admission: 28/8/21
◦ Date of examination: 31/8/21
Chief complaints
◦ Weakness of Right Upper Limb since 6 days
◦ Weakness Of Right Lower Limb since 5 days
◦ Inability to Speak since 3 days
◦ Deviation of angle of mouth to left side since 3 days
History of Presenting Illness
◦ Patient was apparently normal 6 days ago when he developed acute onset weakness
of right upper limb. Patient noticed it at around 8pm when he had difficulty in using his
hand to eat. The weakness progressed over the next three days where the patient had
difficulty in combing hair, lifting arm over head to reach objects, difficulty in holding a
glass of water and was unable to use his right hand to button his shirt.
◦ Acute onset Weakness progressed to right lower limb the next day(5 days ago). He had
difficulty in gripping his slippers which progressed where he had difficulty in climbing
stairs and getting up from a squatting position. Patient was able to continue to walk
without support although with difficulty
◦ 3 days ago patient woke up at 8 am and had lost the ability to speak. He was able to
comprehend speech and follow command but was unable to phrase words or
sentences.
◦ Patient’s attenders also noticed deviation of mouth to left side which was associated
with dribbling of saliva. Patient was able to close his eyes
◦ Patient was recently diagnosed with hypertension and diabetes mellitus
◦ No history of trauma, fever
◦ No history of headache, vomiting
◦ No history of loss of consciousness or seizures
◦ No history of decreased sensation
◦ No history of decreased smell, blurring of vision, double vision, decreased sensation
over face, decreased hearing or vertigo, difficulty in swallowing or nasal regurgitation
on swallowing and no hoarseness of voice
◦ No history of tremors
◦ No history of chest pain or palpitation
Past History
◦ Patient was diagnosed with Hypertension and diabetes 1 month ago
◦ He is currently on amlodipine and metformin
◦ There is no history of similar complaints in the past
◦ No history of transient loss of consciousness or transient blurring of vision/loss of vision in
the past
◦ No history of epilepsy, tuberculosis, heart disease
Family History
◦ No similar complaints in the family
◦ No significant history
Personal History
◦ Diet: Has been on a liquid diet after admission, mixed diet before admission
◦ Appetite: Normal
◦ Sleep: Sound
◦ Bladder: Is able to walk to the washroom and empty bladder on his own. No history of
dribbling of urine
◦ Bowel : Normal
◦ No history of smoking or alcohol intake
◦ No history of high risk behaviour
Summary
◦ A hypertensive and diabetic middle aged man with sudden onset, progressive
hemiparesis of right side including the lower half of right side of face, associated with
aphasia. No history suggestive of sensory deficits or any other cranial nerve
involvement other than UMN lesion of 7th cranial nerve innervating right side of face.
◦ History is suggestive of of acute neurological deficit probably due to ischemic stroke
involving left MCA territory
General Physical Examination
◦ A middle aged man who is moderately build and nourished is conscious and
cooperative and well oriented to time, place and person
◦ Patient is right handed
◦ Pallor: Not seen
◦ Icterus: Not seen
◦ Cyanosis: Not seen
◦ Clubbing: Not seen
◦ Lymphadenopathy: Not seen
◦ Pedal Edema: Not seen
◦ Vitals
◦ Pulse: 71 beats per min, regular, normal in volume and character
◦ Respiratory rate: 16 cycles/ min, abdominothoracic type
◦ BP: 140/94 mm of Hg in left brachial artery
◦ Temperature: 98.6 degree Farenheit
Higher Mental Functions
◦ Right handed individual
◦ Conscious and cooperative
◦ Appearance and Behavior: appropriate. Patient is emotionally stable
◦ Speech: Speech fluency markedly reduced. Incoherent sounds made. Repetition is
absent
◦ Comprehension present
◦ Patient is able to read and follow
Cranial Nerve Examination
Cranial Nerves Right Left
Olfactory Normal Normal
Optic Visual acuity: Counting Visual acuity: Counting
fingers at 6 m fingers at 6 m
Visual field: Normal by Visual field: Normal by
confrontation technique confrontation technique
Pupil: Round and reactive Pupil: Round and reactive
4mm in size 4mm in size
Colour vision: Normal Colour vision: Normal
Fundoscopy: Not done Fundoscopy: Not done
 right left
Occulomotor, Trochlear, Pupil: Size-4mm Pupil: Size-4mm
Abducens Shape normal Shape normal
Light reflex: Both direct and Light reflex: Both direct and
indirect present indirect present
Extraocular movements are Extraocular movements are
normal normal

Trigeminal Sensory: Sensations over Sensory: Sensations over

forehead,cheek,chin are
intact
Motor: Normal
Jaw jerk, corneal and
conjunctival reflex are
normal
forehead,cheek,chin are
intact
Motor: Normal
Jaw jerk, corneal and
conjunctival reflex are
normal
 right left
Facial Forehead wrinkling present Normal
Ability to close eyes present Deviation seen on left
Absence of nasolabial fold
Inability to puff out cheek
Deviation of Angle of mouth
to left
Ant 2/3 taste present
Vestibulocochlear Normal Normal
Glossopharyngeal and Normal Normal
Vagus No deviation of uvula No deviation of uvula
Gag reflex present Gag reflex present
Spinal accessory Normal power of SCM and Normal power of SCM and
trapezius trapezius

Hypoglossal Normal tone. No deviation Normal tone. No deviation

or fasciculations or fasciculations
Motor Examination
◦ Attitude of patient: Patient is in supine position with right shoulder adducted, flexion at
right elbow, flexion at right wrist and semi pronated arm. Right Lower limb is externally
rotated with extension at hip and knee
◦ Bulk
right left
Mid arm 28cm 28cm

forearm 25cm 25cm

Mid thigh 38cm 38cm
Mid leg 30cm 30cm
◦ Tone

Right Left
Upper Limb
Arm Hypotonic Normal
Forearm Hypotonic Normal
Lower Limb
Thigh Hypotonic Normal
Leg Hypotonic Normal
◦ Power
Right Left
Shoulder
Flexion 3 5
Extension 3 5
Abduction 3 5
Adduction 3 5
Internal Rotation 3 5
External Rotation 3 5

Elbow Joint
Flexion 2 5
Extension 2 5
 right left
Wrist
Flexion 1 5
Extension 1 5
Intrinsic Muscles of Hand 1 5
Hip
Flexion 4 5
Extension 4 5
Adduction 4 5
Abduction 4 5
Internal Rotation 4 5
External Rotation 4 5
 Right Left
Knee
Extension 4 5
flexion 4 5
Ankle
Flexion 4 5
Extension 4 5
Toe movements 4 5
Reflexes
◦ Superficial reflexes

Right Left
Corneal Present Present
Conjunctival Present Present
Abdominal Absent Present
Plantar Extensor response Flexor response
◦ Deep Reflexes

Right Left
Biceps 1+ 2+
Triceps 1+ 2+
Supinator 1+ 2+
knee 1+ 2+
Ankle 1+ 2+
Sensory System
right left
Dorsal Column
Fine touch Intact Intact
Vibration Intact Intact
Joint sense intact intact

Spinothalamic column
Pain Intact Intact
temperature intact intact
Cerebellar Functions
◦ Nystagmus: Not seen
◦ Titubation: Not seen
◦ Dysmetria/past pointing: Not seen
◦ Intentional tremors: not seen
◦ Dysdiadokinesia: not seen
◦ Gait: Circumduction gait seen
◦ No signs of meningeal irritation
◦ Examination of skull and spine is normal
◦ Ausculation of neck: no carotid bruit heard
Other systems
◦ Cardiovascular: S1 s2 heard, no murmurs. No carotid bruits heard

◦ Respiratory system: Normal vesicular breath sounds heard. No added sounds present

◦ Abdominal examination: abdomen is soft, non tender. No organomegaly seen

Summary
◦ A middle aged man recently diagnosed with hypertension and diabetes presented
with right hemiparesis ,right UMN lesion of 7th cranial nerve and broca’s aphasia
◦ On examination, patient is able to comprehend speech, in neuronal shock with right
upper and lower limbs showing hypotonia and decreased reflexes. Circumduction gait
seen with no signs of any other cranial nerves, sensory or cerebellar involvement
Provisional diagnosis
◦ Neurodeficit: Right Hemiparesis including upper motor neuron lesion involvement of
right 7th cranial involvement and Broca’s aphasia
◦ Structures Involved: Left MCA territory Internal capsule, broca’s area
◦ Pathologyl: Vascular pathology
◦ Etiology: cerebral vascular accident
Investigation
◦ CT
◦ Diffusion weighted MRI
◦ Perfusion Weighted MRI