PATIENT A.B.

IDENTIFYING DATA

● 63 years old
● Male
● Right-handed
● Filipino
● Married
● Roman Catholic
● Resides in Sta. Mesa
● Known hypertensive for 40 years

2
Chief Complaint
Left-sided weakness
of 19 hours duration

3
 HISTORY OF 19 hours PTA
PRESENT ILLNESS ● Sudden left-sided
weakness
● was still able to walk
to the bathroom
17 hours PTA
● Still with left-sided
weakness
● Associated with left
facial asymmetry and
slurring of speech
● Rushed to Lourdes
Hospital ER.

16 hours PTA (3 hours post-ictus)

● Awake, alert, conversant,
with slurring of speech
● NIHSS score of 14
● 160/90 > 76 > 22 > 36
● Spot CBG: 95
● Hyperacute CVD infarct at
right corona radiata and right
lentiform on plain CT scan

4
 HISTORY OF 16 hours PTA (3 hours post-ictus)
PRESENT ILLNESS ● Aspirin
● Rosuvastatin 20mg ODHS
● Citicoline 1g Q12
● Pantoprazole 40mg OD
● Chest X-ray, ABGs, Blood
16 hours PTA (3 hours post-ictus) test and ECG

● Drowsy, more
difficult to arouse
with unsustained eye
opening to tapping.
● 2nd plain CT scan-
same results

16 hours PTA
(3 hours post-ictus) at the ICU
● Mannitol 150cc Q4
● Aspirin put on hold
● BP; 220/110 mmHg
● Nicardipine started to
maintain MAP at 110mmHg
● MRI was advised.

5
 HISTORY OF
PRESENT ILLNESS

UERM
ER + -
● Drowsy, difficult to ● Slurring of ● Loss of
arouse with speech consciousness
unsustained eye ● Drowsiness ● Headache
opening to tapping, ● Nausea and
slurring of speech Vomiting
● NIHSS score of 15 ● Dizziness

6
PERTINENT HISTORY
● Daytime sleepiness
● Heavy snorer with episodes
of apnea during sleep
● Hypertensive for 40+ years -
previously maintained on
Amlodipine (unrecalled
dosage) for 2 months, non
compliant
● UBP: SBP 200s
● HBP: SBP 200s
● 25 pack/year ● Hypertension - maternal
● Occasional alcoholic ● Type 2 DM - maternal
beverage drinker ● Bone Cancer - maternal
● Denies illicit drug use ● Lung Cancer- Paternal
● Prefers fried, fatty,
oily, and salty foods
● Mechanical Machinist
● College Graduate
7
 General (+) Cold sweats
REVIEW OF SYSTEMS Description No fever, fatigue, sweating, weight loss

Skin No rashes, dryness, pallor, changes in hair and in nails, itchiness,

jaundice

Eyes No visual impairment, redness, glaucoma, tearing, pain, double

vision, discharge, trauma, icteric sclera

Ears No hearing impairment, otalgia, discharge, tinnitus, swelling of

structures

Nose, Throat, No sore throat, gum bleeding, hoarseness, colds, anosmia,

Mouth dysphagia, toothache, ulceration, stuffy nose, epistaxis, odynophagia,
dental caries

Respiratory No cough, difficulty of breathing, orthopnea, exertional dyspnea,

hemoptysis

Cardiovascular No edema, dyspnea, chest pain, syncope, palpitation

Gastrointestinal No vomiting, hypogastric pain, bowel changes, constipation,

heartburn, dysphagia, indigestion, hematemesis, fatty food
intolerance, hemorrhoids, bowel changes 8
REVIEW OF SYSTEMS

Urinary No dysuria, decrease in urine volume, increase in frequency,

nocturia, retention, urinary incontinence, bleeding, dribbling, and
hesitancy

Extremities No clubbing, cyanosis, varicosity, claudication, edema

Hematopoietic No pica, epistaxis, anemia

Nervous No sensory perversions, tremor, fainting spells, seizures, trauma,

tremor

Musculoskeletal (+) Knee pain on walking long walks

No back pain, swelling

Endocrine No heat/cold intolerance, neck surgery/irradiation, polydipsia,

polyphagia, polyuria, thyroid problems

Psychiatric No mood swings and behavioral changes, anxiety, depression

9
 PHYSICAL Non-ambulatory
Ill-looking
EXAMINATION Dirty sclerae
(+) Xanthelasma
Pupils 2mm EBRTL
No visual cuts
(+) Bilateral lens opacities
(+) Primary gaze to the right,
passes midline,
tracks faces and objects

BP: 160/90mmHg
HR: 63 bpm
RR: 18 cpm
T: 36.5°C
O2 Sat: 95% at room air
BMI: 32.3 kg/m2 - Obese
Class II
Cold extremities
Unequal pulses
Strong, +2 pulses on both
upper extremities
Weak, +1 pulses on
dorsalis pedis
10

FRONTAL: Drowsy, unsustained eye opening,
easily arousable when name is called, coherent,
follows command, fluent dysarthria, good insight
and judgement
TEMPORAL: Oriented to 3 spheres
PARIETAL: No R-L disorientation, hemineglect,
agraphia, acalculia, agraphesthesia,
astereognosis, finger agnosia
OCCIPITAL: Can identify familiar
objects and colors
CNI- Can identify substance (Coffee)
CNII- Pupils 2mm EBRTL, no visual cuts
CN III, IV, VI- Primary gaze to the right, passes
midline, Tracks faces, intact EOMs
CN V- Intact V1-V3, (+) corneal reflex
CN VII- Left central facial palsy
CN VIII- Intact bilateral gross hearing
CN IX, X- (+) gag reflex
CN XI- Can turn head side to side,
good shoulder shrug on the right
CN XII- Tongue at midline,
no atrophy, no fasciculations

MOTOR Cerebellar: (-) Nystagmus,

RIGHT LEFT
dysdiadochokinesia, dysmetria
Gait cannot assessed
UE 5/5 1/5 Meningeal: Supple neck, (-) Meningeal
irritation, brudzinski’s, Kernig’s
SENSORY
LE 5/5 2/5 (+) Babinski, Left
100% on all extremities
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Where is the
lesion?
 Nervous
System

Intracranial Extracranial

Supratentorial Infratentorial Spinal Cord

Nerve
Cortex Subcortex Brainstem
(root/peripheral)

Peripheral
Cerebellum
Nerve

NMJ

Muscle
13
WHERE IS THE LESION?

TRACTS INVOLVED:
1. Left hemiparesis —> Corticospinal Tract
INTERNAL 2. Left central facial palsy —> Corticobulbar Tract
3. Slurring of speech —> Corticospinal tract
CAPSULE 4. Preferential gaze to the right —> Pathway for
Horizontal Saccades
5. (+) Babinski, left —> Upper Motor Neuron Lesion

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CORTICOSPINAL TRACT

15
CORTICOBULBAR
TRACT

16
 PATHWAY FOR
HORIZONTAL SACCADE

17
What is the
lesion?
 Stroke

Ischemic Hemorrhagic

Thrombotic ICH

Embolic SAH

19
WHAT IS THE LESION?

● Tend to evolve quickly, but not typically as sudden as an

embolus
● Absent cortical deficits
● Small deep penetrating branches of cerebral arteries
SMALL VESSEL become occluded resulting to small infarcts in the brain
● Seen in chronic HPN, DM, hyperlipidemia
DISEASE ● Mechanism:
(LACUNES) ○ Lipohyalinosis- local type of arteriolar sclerosis
(HPN, DM, hyperlipidemia)
● Common Locations:
○ Putamen, caudate nucleus, thalamus, basis pontis,
internal capsule, deep in central hemisphere white
matter
20
WHAT IS THE LESION?

21
Diagnostics
 ● Repeat plain cranial CT scan
● Cranial MRI with DWI and MRA
● Lipid profile and uric acid
2D echo, carotid duplex scan and 24 hour holter
Diagnostics ●
monitoring
● Sleep study once more stable
● AV duplex scan of both lower extremities
● Baseline ABGs, 12-lead ECG

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MANAGEMENT

2
4
Goals of Management

Recanalization/Reperfusion Fibrinolytic therapy/ Thrombolysis

Primary Goal (IV, Intra-arterial)
• Cilostazol 50mg/tab BID

Acute stroke unit/ ICU admission

Antithrombotic
Supportive Treatment
Prevent Neurologic Worsening • Atorvastatin 80mg/tab ODHS
Prevent Early Recurrence • Mannitol 175 cc IV Q4
Prevent Complications • Elevate head of bed 30 degrees
• NGT feeding
• Hook to oxygen at 2 LPM
Goals of Management

Neuroprotection
Preserve Ischemic Tissue • Citicholine 1 g BID
(Penumbra) • Maintain Permissive hypertension (MAP 110-130 mmHg)
OUR TEAM

THANK YOU!

THANK YOU!

THANK YOU!

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