Cerebral Thrombosis

7/31/2019 Cerebral Thrombosis

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CASE REPORT

CEREBRAL THROMBOSIS

Mei Risanti Sirait, S. Ked (04104705362)

Preceptor : dr. H. A. Rachman Toyo, SpS(K)


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NEUROLOGY MEDICAL

RECORD


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IDENTIFICATION

Name : Mr. A

Age : 50 years

Sex : Male

Address : Jl. Srijaya Lorong Bersama No

1056, Alang-alang Lebar

Religion : Moslem

Admission date: May 21st, 2012


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ANAMNESIS

The patient was admitted to

Neurology department of Moh Husein

General Hospital because of theweakness on his right arm and lower

limb which happened suddenly.


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21 hours before admission to the

hospital, while resting, suddenly he feltweakness on his right arm and lower

limb without decrease of consciousness.

At that time, he didnt experienceheadache, nausea and vomit, stiffness or

disturbance of sensibility on the right

side. The weakness between his rightarm and lower limb was similiar degree.


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The patient is right handed. He could

express by speech, hand writing and

geasture. The patient understood other

peoples mind which was expressed by

talking, writing and giving sign. When he

talked, his mouth deviate and experience

slurred speech. He had no complain

about urination and defecation.


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There are no previous history of headache

in the morning, history of getting painless

lession and self healing in the eksternal genital

and his wife has no history of abortion in > 16weeks. There's no history of hypertension and

diabetes mellitus.

This illness was the first time for him.


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PHYSICAL EXAMINATION

Internal State

Sense : compos mentis

(E4M6V5)

Nutrition : adequate

Pulse : 86 beats/min

Respiratory rate: 20 times/min

Blood pressure : 180/100 mmHg

Temperature : 37,20C


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Weight : 70 kg

Height : 172 cm (BMI: 23,61)

Lungs : no abnormality Liver : no abnormality

Spleen : no abnormality

Extremities : see neurological state Genital : no abnormality


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Neurological state

N. I : anosmia (-), parosmia (-)

N. II : anopsia (-), hemianopsia (-),edema papil (-), papil atrophy (-),

retina bleeding (-) N. III, IV and VI: pupil round, 3mm isochor,

light reflex (+/+)

OD OS


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N. V : corneal reflex (+), bitting (+),

normal, no sensory deficit in

trigeminal area

N. VII : right nasolabial fold slightly flat,

asymetric facial shape

N. VIII : no abnormality

N. IX and X: pharyngeal arc are symmetrical,

uvula located in central, nodisturbance of swallowing and normal

voice


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N. XI : no weakness in lifting shoulder and

turning head around

N. XII : deviation to the right, noatrophy papill, fasiculation and

dysarthria


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Motoric Function

Right Arm Left Arm Right Limb Left Limb

Motion

StrenghtTone

Clone

Physiological

Reflex

Pathological

Refllex

Insufficient

4

-

-

Sufficient

5N

N

-

Insufficient

4

-

+ (B)

Sufficient

5N

N

-


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Other Neurologic Function

Sensory Function : no abnormality

Vegetatif Function : no abnormality

Higher cortical function : no abnormality Meningeal sign : -

Abnormal movement : -

Gait and postural : -


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Laboratory Finding

BLOOD (May 23rd, 2012)

Hb : 14,9 g/dl ( 14 18 )

Ht : 44 ( 40 - 48 )

Leukocyte : 7300/mm3 ( 5000 - 10.000 )

Trombocyte : 226.000 ( 200.000 500.000 ) DC : 0 / 3 / 1 / 62 / 22 / 10

BSS : 113 mg/dl

HDL : 35 mg/dl ( < 55 )

LDL : 146 mg/dl ( < 130 )

Trigliseride : 103 mg/dl ( < 150 ) Uric Acid : 5,3 mg/dl ( 3,5 7,1 )

Ureum : 19 mg/dl ( 15 39 )

Creatinine : 1,1 mg/dl ( 0,9 1,3 )


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Spesific Examination

1. Chest X-Ray : normal chest

2. Brain CT-Scan : Infarct ischemic in left radiate

corona.


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Sli h h d l i


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Slight hypodense lession

with uncertainty border in

left corona radiata

Sulci, fissura of sylvii and

gyrii in good condition

Gray and white matter

differentiation are clear

No deviation on midline

Infrateritorial: pons,

cerebellum are in goodcondition

Ventricles and cysternae

system is not narrow, magna

cysternae is prominent

Air cell pneumatitation forright and left mastoid is good

Occuli bulbi and left and

right retroorbita area are

good


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Diagnosis

A. Clinical Diagnosis :1. Right hemiparesis spastic type

2. Right VII nerve palsy centre type

3. Right XII nerve palsy centre type

B. Topical Diagnosis :

Left interne capsule hemisphere

C. Etiological Diagnosis :

Cerebral thrombosisDD: 1. Cerebral hemorrhage

2. Cerebral emboli

3. Cerebral thrombosis


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Management

- Bed rest

- low salt semi solid diet

- IVFD RL gtt xxx/M- citicholine 2x250 mg IV

- aspilet 1x80 mg tab

- Vitamine of B1,B6,B12 3x1 tab


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Prognosis

Quo ad vitam : bonam

Quo ad functionam : dubia ad bonam


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THANK YOU


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Topic Diagnosis


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1. Lession in left cerebral cortex

hemisphereLession in left cerebral

cortex hemisphere, the symtomps:

The symtomps found in the

patient:

Motoric deficit (right

hemiparesis)

Iritative symtomps (seizure

on the right side)

Focal symtomps (The

paralysis is not similiar )

Sensoric deficit on the

paralysed side

Right hemiparesis spastic type

No seizures on the paralysed side

The paralysis of right arms and

right lower limb are similiar

No sensibility disorder on the right

side body


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2. Lession in left cerebral subcortex

hemisphere

Lession in left

cerebral subcortex

hemisphere, the

symtomps


patient:

Motoric deficit

(hemiparese

dextra)

Motoric aphasia

Right hemiparesis spastic

type

No pure motoric aphasia


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The possibility of lession in left

interne capsule hemisphere canbe made as topic diagnosis .


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Etiological Diagnosis


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Siriraj Stroke Score

(2,5 x level of consciousness) + ( 2 x Vomity) +

( 2 x Headache) + (0,1 x diastolic blood

pressure) (3 x atheroma marker) 12

: (2,5 x 0 ) + ( 2 x 0) + (2 x 0) + (0,1 x 90) (3 x

0) 12

: 0 + 0 + 0 + 9 0 12

: - 3

Conclusion : Non cerebral haemorrhagic


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1. Cerebral haemorrhagic

The symtomps: The symtomps found in

the patient:

- Unconciusness > 30 minutes

- Contralateral Hemiparesis

centre

None

None

2. Cerebral emboli

The symtomps: The symtomps found in the

patient:

- Unconsciousness < 30 minutes None

- Arterial fibrillation None


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3. Cerebral thrombosis

Thrombosis cerebri, the

symtomps:


patient:

-Without unconsciousness

-- Happen in resting time

- Without unconsciousness

- Happen in resting time


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At kl i


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Aterosklerosis


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THERAPEUTIC WINDOWJENDELA PENGOBATAN

0 -4- 6 hr : POTENTIAL FULL RECOVERY

612 hr : POTENSTIAL PARTIAL RECOVERY

12

24 hr : POSSIBLE RECOVERY

2436 hr : START OF INFARCTION


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Repairing depends on

Type of stroke

Extent of ischaemic

Collateral system

Immediate therapy

It was first attack

Power of right arm and limb is 4

There is no unconscioussnes

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