A CASE PRESENTATION

ON ACUTE ISCHAEMIC
STROKE
MODERATOR- Prof. Dr. S. K. Baruah,
Head of Department,
Department of Medicine,
Gauhati Medical College and Hospital

PRESENTED BY- Students of 8th Semester

ROLL NUMBER NAME
1 Anindya Bikas Dutta
2 Mayur Hazarika
3 Prajnan Jyoti Bhardwaj
4 Geetashree Haloi
5 Namrata Chakravarty
6 Pragya Bhattacharjee
7 Nimisha Sharma
CASE HISTORY
Name- Mijing Sangma
Bed No.- 455
Age- 55 years
Sex- Male
Religion- Hindu
Educational Status- HS Passed
Occupation- Company Worker
Address- Maligaon, Guwahati
Date and time of admission- 5th March, 2019 at around 1:30pm
Date and time of examination- 6 th March, 2019 at around 6:00pm
CHIEF COMPLAINTS

Weakness of the right side of body for last 2 days

Difficulty of speech for last 2 days

Deviation of face to the right while eating for last 2 days

HISTORY OF PRESENT ILLNESS
The patient, a 55 year-old Company Worker, complains of weakness of
the right side of his body for last 2 days. At the onset, when he woke up
at 7 am the morning of 5th March, 2019, he suddenly felt weak on the
right side of the body and was unable to get up. His son tried to help
him sit up, but he fell onto his right side. The episode was sudden in
onset and the evolution of the paralysis was completed within 5 hours.
The weakness was felt equally both in the right upper and lower limbs.
He had difficulty in buttoning his shirt, having his meal, combing his
hair and brushing, as well as in keeping his slippers on and getting up
from squatting. However, he could feel his clothes on his body.

He was suffering from speech difficulty since the onset of the episode.
The speech is slurred; however he can understand and reply to others.
HISTORY OF PRESENT ILLNESS (continued)

He also complains of deviation of the face to the right side during

eating, speaking or attempted smiling with drooling of saliva since
the onset of this episode.

There was no waxing or waning of symptoms, no history of

headache, vomiting, convulsions, loss of consciousness; palpitation,
breathing difficulty, shifting of the weakness; sensation of burning or
tingling; sweating, loss of bowel and bladder control, flushing,
dizziness on standing; abnormal smell perception, double vision, loss
of sensation over face, difficulty in chewing or swallowing, nasal
regurgitation or nasal intonation.

His appetite is normal, his sleep is not disturbed, his bowel and
bladder habits are normal.
COURSE DURING HOSPITAL STAY

The patient was initially taken to Mahendra Mohan

Choudhury Hospital, Panbazar where a few investigations
were undertaken and referred to Gauhati Medical College
and Hospital. During his stay here, there was no further
progression or resolution of weakness.
HISTORY OF PAST ILLNESS
There is no history of similar type of episodes in the past.

He was diagnosed with tuberculosis 25 years ago and accordingly

took medications, but is unable to recall if he could complete the
course. He also had a minor traffic accident 15 years back and the
recovery was uneventful.

There is no past history of head injury, fever, difficulty in breathing,

pain chest, bleeding disorder, convulsions. He is not known to be
hypertensive or diabetic. He does not take anticoagulants or aspirin
and there is no exposure to STD. There is no history of recent weight
loss.
PERSONAL HISTORY
The patient consumes an average non-vegetarian Assamese
diet consisting of three major meals a day. He is a non-
alcoholic and a non-smoker, but has been consuming tobacco
with betel nut for 30 years now.
FAMILY HISTORY
There is no history of similar episodes among other members
of the family. Neither are there any cases of hypertension,
diabetes mellitus, epilepsy or migraine in the family.
SOCIOECONOMIC HISTORY

The patient lives with his wife and his son in a pukka house with
four rooms and a separate kitchen and a bathroom. They use LPG
as a source of fuel for cooking. They take water from the well and
filter it before use. They use sanitary latrine and dispose garbage in
community dumps. They rear no livestock or poultry.

Their monthly income is Rs. 24,000 and the per capita income is
Rs. 8,000.
DRUG HISTORY

There is history of intake of antitubercular drugs 25 years ago.

There is no history of intake of anticoagulants or aspirin, or
any other long term use of drugs.
ALLERGY HISTORY

The patient is not allergic to any known ingestant, inhalant or

contactant.
IMMUNIZATION HISTORY

The patient could not specify about his immunization history.

BCG scar is present.
GENERAL EXAMINATION (as done on 6th March, 2019)

 Appearance: patient looks ill

 Consciousness: will be described in the CNS examination part
 Decubitus: supine
 Built: average
 Nutrition: fair
 Height: 157cm
 Weight: 54kg
 BMI: 21.9
 Hair and skin: normal in colour and texture
 Icterus: absent
 Pallor: absent
 Cyanosis: absent
GENERAL EXAMINATION (continued)

 Teeth and gums: Healthy

 Condition of oral cavity and tongue: Healthy
 Neck Vein: not engorged
 Jugular Venous Pulse (JVP): Normal
 Neck glands: not palpable
 Lymph nodes: not palpable
 Clubbing: absent
 Koilonychia: absent
 Oedema: absent
GENERAL EXAMINATION (continued)
Vitals
 Respiratory Rate: 18/ min, regular in rhythm, and abdomino-thoracic type

 Blood Pressure: 140/100 mm Hg in right upper arm in supine position

 Pulse: 64 beats per min

• Regular in rhythm
• Normal in volume and character
• Condition of the arterial wall is normal
• No radio-radial and radio-femoral delay found
• All other peripheral pulses are bilaterally and symmetrically palpable

 Temperature: 36.2oC (97.16oF)

SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM EXAMINATION

1. Examination of the Higher Functions:

 Appearance: Normal
 Behaviour: Cooperative
 Consciousness: Alert and well-oriented to time, place and person, Glasgow
Coma Scale-13/15
 Delusion/Illusion/Hallucination: Absent
 Emotional status: Normal
 Memory: Intact
 Handedness: Right-handed
 Speech: Normal
 Intelligence: Normal
 Judgemental Capacity: Normal
2. Examination of Cranial Nerves

 CRANIAL NERVE- I
Sense of smell on each nostril Normal

 CRANIAL NERVE- II
Visual acuity( distant and near) Normal in both eyes
Visual field Normal in both eyes
Colour Vision Normal in both eyes
Fundoscopy Not done

 CRANIAL NERVES- III, IV, VI

Eye position and extra ocular muscle movements Normal in both eyes
Power of extra ocular muscles Normal in both eyes
Pupil size and shape Normal in both eyes
Pupillary Light reflex( direct and consensual) Present on both eyes
Accommodation Reflex Present in both eyes
 CRANIAL NERVE- V
Motor function (Masseter, pterygoids, temporalis) Normal on both sides
Sensory function(Sensation over the face) Normal
Corneal reflex(both eyes) Normal
Jaw jerk Normal

 CRANIAL NERVE- VII

Muscles of Facial expression - Flattened nasolabial fold, angle of mouth
deviated to left, weakness of buccinator, orbicularis oris, platysma on the
right, upper face on right side normal
Taste over anterior 2/3rd of tongue Normal
Muscles of mastication Weakness on the right side
 CRANIAL NERVE- VIII
Tuning fork tests-
• Rinne’s test Normal on both ear
• Weber’s test Normal on both ear
• ABC test Normal on both ear
Vestibular tests Not done

 CRANIAL NERVE- IX
Gag reflex Not done
Taste over posterior 2/3rd of tongue Normal

 CRANIAL NERVE- X
Palate movements Normal

 CRANIAL NERVE- XI
Power of Trapezius and Sternocleidomastoid Could not be elicited on right side

 CRANIAL NERVE- XII

Power of tongue muscle Normal
3.Examination of Sensory Function
LEFT RIGHT
1)Superficial-
• Pain Normal Normal
• Touch Normal Normal
• Temperature Normal Normal
2)Deep-
• Vibration sense Normal Normal
• Pressure sense Normal Normal
• Joint sense Normal Normal
• Position sense Normal Normal
3)Cortical-
• Tactile localisation Normal Normal

• Two point discrimination Normal Normal

• Stereognosis Normal Normal
• Graphaesthesia Normal Normal
4. Examination of Motor Functions

1) Muscle bulk:
• normal on both sides.
• no wasting or hypertrophy, fasciculation and involuntary
movement of muscles.

2) Assessment of muscle tone:

Limb Right Left
Upper limb Hypertonic Normal
Lower limb Hypertonic Normal
3) Assessment of muscle power:
Limb Right Left
• Upper limb 1/5 Normal
• Lower limb 1/5 Normal

4) Examination of limb co-ordination:

Test Right Left
• Finger nose test Could not be assessed Normal
• Heel shin test Could not be assessed Normal

5) Involuntary movements: No abnormal movements

seen.
5. Reflexes
Superficial reflexes Right Left
• Plantar reflex Extensor Flexor
• Abdominal reflex Absent Absent
• Cremasteric reflex Not done

Deep reflexes Right Left

• Biceps jerk Exaggerated Normal
• Triceps jerk Exaggerated Normal
• Supinator jerk Exaggerated Normal
• Knee jerk Exaggerated Normal
• Ankle jerk Exaggerated Normal
Primitive reflexes like snout reflex, glabellar tap, palmo-
mental reflex, grasp reflex are absent.

Clonus
• Ankle clonus: Absent on both sides.
• Patellar clonus: Absent on both sides

6. Trophic Changes Absent

7. Cerebellar Function Within Normal Limit

8. Stance and Gait Could not be assessed

9. Peripheral Nerves Examined and found intact

10. Signs of meningeal irritation

• Neck rigidity Absent
• Brudzinki’s sign Negative
• Kernig’s sign Negative
CARDIOVASCULAR SYSYTEM EXAMINATION

 Inspection:
Shape and size of the Precordium is normal.
No bulging or visible pulsations are seen.
Palpation:
Apex beat is felt in the 5th intercostal space just inside the
mid-clavicular line.
Auscultation:
1st and 2nd heart sounds are heard normally.
No additional heart sounds are heard.
RESPIRATORY SYSTEM EXAMINATION
 Inspection
• Shape and size of the chest is normal
• Movement of chest is bilaterally symmetrical
• Respiratory rate is 18/ minute, regular in rhythm and abdomino- thoracic in nature
• No scar marks or skin pigmentation or any visible pulsation

 Palpation
• Trachea is in midline
• Chest expansion is normal
• Vocal fremitus is bilaterally symmetrical and normal

 Percussion
• Lung field is uniformly resonant in all areas

 Auscultation
• Normal vesicular breath sounds are heard and no additional sounds are heard.
• Vocal resonance is normal on both sides.
GASTROINTESTINAL SYSTEM EXAMINATION
 Inspection:
• Shape and size of abdomen is normal.
• No visible pulsation and scar mark present.
• Umbilicus is inverted and in the midline.
• No hernia present.
 Palpation:
• Superficial Palpation- No raised temperature and No tenderness
• Deep Palpation- Liver- Not palpable
Kidney- Not palpable
Spleen- Not Palpable
 Percussion:
• Upper border of Liver present at 4th intercostal space
 Auscultation:
• Bowel sounds heard
PROVISIONAL DIAGNOSIS

The patient is provisionally diagnosed to be a case of stroke

with right sided hemiplegia without speech defect, sensory,
cranial nerve, bladder and bowel involvement; probably due to
lesion in the left internal capsule of ischaemic etiology, due to
thrombosis of lenticulostriate branch of the middle cerebral
artery, possibly due to systemic hypertension.
INVESTIGATIONS

HAEMATOLOGICAL INVESTIGATIONS (dated 5/3/19)

 WBC 12.01 [ 10^3 /uL] (4-11)

 HGB (male) 13.4 [g/dL] (14-16)
 PLT 238 [10^3/uL] ( 150-400)
SERUM INVESTIGATIONS

 Glucose(random) 97. Mg/Dl 80-120

 Urea 64.9 Mg/dL 19.3-42.8
 Creatinine 1.2. Mg/dL .5 - 1.3
 Sodium 139 mmol/L 137-145
 Potassium 4.9 mmol/L 3.5-5.1
 Total bilirubin 1.3. Mg/dL .2-1.3
 • Unconjugated 7. Mg/dL 0.0-1.1
 • Conjugated 0.0. Mg/dL 0.0-.3
 • Delta bili 6. Mg / dL
 ALT 50. U/L 17-59
 AST 31. U/L 21-72
 Albumin 4.5. g/dL 3.5-5
 Total protein 8.3 g/dL 6.3-8.2
SERUM INVESTIGATIONS

Cholesterol 170 Mg/dL 0-200

Direct HDLC 54 Mg/dL 40-60
LDL 101 Mg/dL 0-130
VLDL 16 Mg/dL 0-50
Triglycerides 80 Mg/dL 0-150
C/H 3
TSH 2.55. mIU/L .465- 4.68
NEUROIMAGING STUDY
Non- Contrast CT (NCCT)- Serial axial and saggital sections of
the brain were studied without using I.V. contrast media
Study shows-
A hypodense area in the left periventricular area and the
capsuloganglionic region (left MCA territory)
Cerebral atrophic changes seen
Mass effect with compression of left ventricle seen
Posterior fossa contents including cerebellar hemispheres,
vermis and 4th ventricle are normal
Bony calvarium normal
CT Features suggestive of Ischemic etiology
ELECTROCARDIOGRAPHY (ECG)- Findings are normal

CAROTID ARTERY DOPPLER has been done

ECHOCARDIOGRAPHY has been done
But reports are not available yet
FINAL DIAGNOSIS

The patient MIZING SANGMA, 55 yrs old hailing from

Maligaon, is diagnosed to be a patient of ACUTE
ISCHEMIC STROKE with RIGHT SIDED
HEMIPLEGIA AND RIGHT SIDED UMN TYPE
FACIAL PALSY.
SUMMARY

The patient Mr. MIJING Sangma ,55 yr old complained

of weakness on the right side of the body for the last two
days which was sudden in onset and the evolution was
complete within 5 hours.
The patient also had deviation of angle of mouth to the
left side while eating , speaking or smiling since day one
which was acute in onset.
History of tuberculosis 25 years ago and took medications
but could not recall if medications were taken for a full
course.
On examination , patient is conscious , alert Gcs
scale=13/15. Weakness of right side of body with
paralysis of lower right side of face. There is increases
tone of right lower and upper limbs, exaggerated tendon
reflexes and extensor plantar response. Neurological
examination of the left side was normal.

The patients history and examination suggests that the

patient is suffering from acute Ischemic stroke with
right sided hemiplegia and left sided UMN facial nerve
paralysis.
MANAGEMENT
Management of Ischemic Stroke is aimed at minimising the
volume of Brain i.e irreversibly damaged preventing
complications and reducing the patient’s disability and
handicap through rehabilitation and reducing the risk of
recurrent stroke or other vascular events.
Treatments designed to lessen the amount of Tissue
infarction and improve the clinical outcomes fall within
Six categories –
1. .MEDICAL SUPPORT
Rapid admission of patients to hospital or specialised stroke unit facilitates
co-ordinated care and has been shown to reduce both mortality and
disability rates.
The Medical supportive measures includes –
AIRWAY - Maintain airway , perform a bedside swallow screen, keep
patient nil per oral if swallowing is unsafe or aspiration occurs
BREATHING- Maintain oxygen saturation , monitor respiratory rate ,
oxygen saturation if saturation <95%
CIRCULATION- Peripheral perfusion, blood pressure, pulse should be
monitored and treatment to be done by fluid replacement, antiarrhythmics
and inotropes
HYDRATION- Prevent dehydration, if dehydration present , give fluid
parenterally or by nasogastric tube
NUTRITION- nutritional supplements and nasogastric feeding if dysphagia
persists >48 hrs
 MEDICATION- if dysphagic , consider other routes for essential medications
 BLOOD PRESSURE- Unless indicated ( heart failure/ renal failure, hypertensive
encephalopathy or aortic dissection) it should not be lowered for the fear of
expansion of infarct.
 BLOOD GLUCOSE- Insulin to treat hyperglycemia (>200mg/dl) as it can
increase infarct size.
 TEMPERATURE- If pyrexic, treat the underlying cause control with antipyretics
(as raised brain temperature can increase infarct size)
 PRESSURE AREAS- To prevent occurrence of decubitus ulcers by providing
pressure relieving mattresses, treatment of infections, maintenance of nutrition,
turn immobile patients regularly.
 INCONTINENCE- Check constipation , urinary retention and treat these
appropriately. Avoid urinary catheterisation unless patient is in acute urinary
retention or incontinence is threatening pressure areas
 MOBILISATION-Avoid bed rest.
2. REPERFUSION (Thrombolysis)
Recombinant tissue plasminogen activator (rTPA)- Alteplase 0.9mg/kg(max
90mg) 10% of dose – initial IV bolus, remainder to be infused over 1 hr to be
used < 3hrs of onset of symptoms (for maximum efficacy). Haemorrhage to be
ruled out before rTPA administration.

3. ENDOVASCULAR REVASCULARISATION-
Includes ENDOVASCULAR MECHANICAL THROMBECTOMY indicated
for patients who have contraindication to thrombolytics or in those who failed
to achieve vascular recanalisation with IV thrombolytics

4. ANTIPLATELET THERAPY- Aspirin, Clopidogrel (act by inhibiting

platelet aggregation and adhesion)- Aspirin 300mg single dose to be given
immediately following diagnosis, if alteplase is given it can be withheld for 24
hrs. Later aspirin at a dose of 75 mg in combination with clopidogrel 75mg daily
for about one year duration.
5. ANTICOAGULANTS- HEPARIN which act by accelerating the inhibition of
factor II & factor X of coagulation cascade.
• WARFARIN- Antagonises vitamin K to prevent activation of clotting factors
• Anticoagulants decrease the risk of recurrence and venous thromboembolism,
intracranial haemorrhage to be excluded before therapy

6. NEUROPROTECTION- It is a concept of providing a treatment that prolongs

the brain tolerance to ischemia and blocks the excitatory amino acid pathways but are
still under clinical trials.

7. STROKE CENTRES AND REHABILITATION- It includes-

• Physiotherapy
• Pneumatic compression stockings to prevent risk of DVT
• Occupational therapy
• Speech therapy
• Improve quality of life with motor aids – leg brace, toe spring, cane, walking stick etc
SECONDARY PREVENTATION INCLUDES
BP control
Diabetes management
Lipid management
Smoking cessation
Alcohol moderation
Weight reduction, physical exercise
Antiplatelet Agents
Carotid Artery Interventions-Carotid Endarterectomy ,
Angioplasty
Statins
Diuretics or ACE inhibitors
THANK YOU