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General Data. DS 65 year old Female Right- handed. Chief Complaint. “Numbness of the left hand”. History of Present Illness. One hour PTA, (+) inward movement and numbness of the left hand (-) blurring of vision, palpitations, tremors, nausea, vomiting, dizziness, sweating - PowerPoint PPT Presentation
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General Data• DS• 65 year old• Female• Right- handed
Chief Complaint
• “Numbness of the left hand”
History of Present Illness
• One hour PTA, – (+) inward movement and numbness of the
left hand– (-) blurring of vision, palpitations, tremors,
nausea, vomiting, dizziness, sweating– (+) disorientation and confusion– (+) stiff?– Rapid and incoherent speech
History of Present Illness• At the ER,
– Two episodes of generalized tonic- clonic seizures• lasting 1- 2 minutes • stiffening and jerking of the upper and
lower extremities • head tilted to the right • eyes rolling upward• tongue biting
History of Present Illness
• At the ACSU– throbbing headache located on the top of her
head,(6/10)– (+) generalized weakness– (-) urinary incontinence, blurring of vision,
nausea or vomiting– (-) memory of what happened
Review of Systems
• General: (-) fever, weight loss• HEENT: (-) tinnitus, colds• Respiratory: (-) difficulty of breathing, coughing• Cardiovascular: (-) chest pains, orthopnea,
PND• Gastrointestinal: (-) change in bowel
movements
Review of Systems• Genitourinary: (-) dysuria, frequency• Endocrine: (-) heat or cold intolerance, excess
thirst, excess sweat• Musculoskeletal/ Dermatologic: (+)
dermatoses/ trophic skin changes
Past Medical History
• Illnesses– Seizure secondary to CVD infarct January
2010– Angina 2007 – Hypertension – Diabetes mellitus type 2 2000
• (-) Trauma• (-) History of febrile seizures
Past Medical History• Surgeries: None• Hospitalization: January 2010• Allergies: None
Past Medical History• Ob- gyne
– G3P3(3003) – LMP 55 years old– (+) OCP use for 6 months– (-) hormone replacement therapy– (+) preeclampsia: third pregnancy– (+) blood transfusion: third pregnancy
Medications
• Compliant with:1) Lantus 40 mg SQ OD2)Aspirin 75 mg OD3)ISMN (Imdur) 60 mg durule4)Bisoprolol 10 mg OD5)Perindopril 8 mg OD6)Atorvastatin 20 mg/ tab OD7) Dipyridamole 200 mg/ tab OD
Family Medical History• Diabetes• Hypertension• Breast Cancer• Stroke• Cardiovascular disease
Personal and Social History• Married with three children • Occupation: nurse• Occasional drinker• Non- smoker
Physical Examination
Physical Examination• Awake, not in cardiorespiratory distress• Height: 165 cm• Weight: 80 kg• BMI = 34• BP = 160/70• HR = 73• RR = 14• T = 36.5OC
Physical Examination
• HEENT– Anicteric sclerae; pink palpebral conjunctiva– No nasal congestion– (-) CLAD, (-) TPC, Non- distended neck veins
• Respiratory– Symmetric chest expansion– Clear breath sounds
Physical Examination• Cardiovascular
– Adynamic precordium– Apex beat at 5th ICS LMCL– Regular rhythm, normal rate– Distinct S1 and S2– (-) Murmurs
• Abdominal– Flabby, soft abdomen– Normoactive bowel sounds– No tenderness
Physical Examination• Extremities
– Full and equal pulses (2+)– (-) edema– Good skin turgor
• Skin– Normal hair and scalp, nails– Trophic skin changes/ dermatoses– No pallor or jaundice
Physical Examination• Neuro examination at the ER:
– Awake, still confused and disoriented, able to follow some verbal commands; GCS 14
– Primary gaze: midline disconjugate gaze, initially oscillopsia on extreme gaze.
– CN II- pupils are equally reactive to light 3 mm; CN III, IV, VI- EOMs full and equal; CN V brisk corneal reflex; CN VII no asymmetry or weakness; CNXIII intact; CN IX- X (-) dysarthria, dysphagia; CN XI no weakness; CN XII tongue midline.
Physical Examination• Neuro examination at the ER:
– Motor 5/5 on all extremities except for the left upper extremity 4/5. Minimal spasticity on the left. Left arm can lift 30˚.
– Sensory intact. – Supple neck– (-) Babinski reflex– (-) hyper, hyporeflexia
Physical Examination• Neurologic :• MMSE: 28/ 30; GCS 15
– Cranial Nerves• I – Not done• II – Pupils 3mm, equally reactive to light; visual fields full to
confrontation• III, IV, VI – Full EOM’s• V – Corneal reflex not done, sensory- intact bilaterally in all three
divisions for sharp, dull, touch stimuli; motor- temporal and masseter strength intact
• VII – No facial weakness and asymmetry• VIII – Gross hearing intact• IX, X – (+) gag reflex
• Neurologic :• Cranial Nerves (cont.)
• XI- (+) shoulder shrug, head turn, 5/5• XII – tongue at midline
Physical Examination• Neurologic
– Motoro (-) muscle, involuntary movementso 5/5 on all extremities except for left upper extremity (4/5)o Drift on the upper left extremityo DTRs: ++ on bilateral brachioradialis, ankle; (-) Babinski
– Somatico Reactive to touch/pain on all extremities. Temperature sensation
intact bilaterally and symmetrically. Position sense intact bilaterally and symmetrically intact except for left upper extremity
– Cerebellaro No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel
along shin intact bilaterally)– Supple neck, (-) Brudzinski, Kernig's
Initial Impression
• Post stroke seizure
• s/p CVD infarct– Right MCA and left sided residuals, mRS 3
• Hypertension Stage II• Diabetes Mellitus Type 2
Differential Diagnoses
Syncope
Rule In Rule OutLoss of consciousness -No precipitating factors
-LOC and GTC movements <15-30 seconds- Loss of postural tone-Rare tongue biting and headache
Transient Ischemic Attack
Neoplastic
Rule In Rule Out-Family history of cancer-Focal neurologic deficit
-No chronic headache which worsens over time-No weight loss, nausea, vomiting, irritability
Infection
Rule In Rule Out-No fever, nausea, vomiting, irritability-Supple neck, (-) Kernig's and Brudzinski
Stroke
Rule In Rule Out-Headache, confusion, lapse of consciousness-(+) hypertension, diabetes mellitus
Hypoglycemia
Rule In Rule Out- Good compliance- Does not skip meals
Migraine
Rule In Rule Out-Talkativeness-Altered consciousness and headache-Unilateral weakness
-Prolonged unilateral headache -Duration of headache can last for hours-Seizure?
Initial Imaging Studies• Head CT
– Wedge shaped I'll defined hypodense focus is seen in the cortical subcortical region of the right parietal lobe.
– Underlying gyrus and sulci are effaced. – Patchy hypodensities along the periventricular
white matter of both frontal and parietal lobes are also noted.
– The rest of the grey-white matter interface is maintained.
Initial Diagnostics• CT
– Malacic changes • CBC
– Hgb 138– Hct .42– WBC 8.5
• N .72• L .24• M .04
– PC 137
• PT 12.2• INR 0.89• ALT 27.04• BUN 4.48• Creatinine 99.01• Na 137• K 3.9• Lipid Profile (results to follow)
Initial Management• Phenytoin
– Loading dose 1gm– Maintained at 100 mg/cap TID
• Admit to ACSU– Cardiac, CBG monitoring– O2 Support, seizure precautions
• Diazepam 5 mg IV• Ketorolac 30 mg IV then q8 prn for headache• Continue maintenance medications
Day 1 -3 (Nov 7-9)S O A PNo recurrence of seizureSome difficulty sleeping
GCS 15Stable vitalsClear breath sounds NRRR, distinct S1/S2Soft abdomen
CBG=256 mg/dL
Post-stroke seizureHypertensionDM 2
Dx:MRI, MRA, MRV (Nov 8 )Tx:Citicoline Insulin glulisine
Possible discharge Nov. 11
Imaging Results
• Cranial MRI– Wedge-shaped Right inferior parietal cortical-
subcortical encephalomalacia, gliosis and siderosis, presumably sequelae of a previous water-shed type infarction with hemorrhagic conversion
– Mild microvascular white matter ischemic changes on the left centrum semiovale
– Mild central cerebral volume loss
Imaging Results
• MRA: No aneurysm or any significant stenosis or vascular malformations seen
• MRV: No evident cortical vein or dural sinus thrombosis
Day 4 (Nov 10)S O A PAsymptomatic: (-) palpitations, chest pain, dizziness
Atrial Fibrillation in RVR recorded for 3 hours (3:40 am)
Paroxysmal AF Dx: 12L ECGTx: BisoprololCardio referral
Cardio: BP 116 / 77HR 52Sinus bradycardiaGood S1, NRRR (-) carotid bruit
Paroxysmal AF, now back in sinusHypertension, stage 2
Dx: 2D ECHO TFTsTx: Amlodipine, Enoxaparin,Clonidine,ISMN
Neuro:No recurrence of seizures
MRI/MRA/MRVCholesterol 3.75 (3.4 – 5.2)HDL 2.33 (high)LDL 1.39Triglycerides 0.93vLDL 0.42
Post Gliotic SeizureCVD infarct, Right MCA
Tx: Levetiracetam, Sitagliptin
Diagnostics• ECG: Atrial Fibrillation, RVR• TFT:
– TSH 3.01 uIU/mL– FT3 2 pg/mL– FT4 0.83 ng/dL
• EEG: abnormal EEG due to a focal theta slowing on the right temporo-parietal occipital region with wave epileptiform discharges on the right temporo-occipital region consistent with a focal cerebral dysfunction and a tendency toward localization-related seizures at the right temporo-occipital region
Day 5-7 (Nov 11-13)S O A P
Neuro/Cardio:AsymptomaticComfortableNo recurrence of AF, seizures
GCS 15Stable vitalsClear breath sounds NRRR, distinct S1/S2Soft abdomen
Post-Gliotic SeizureParoxysmal AFHypertensionDM 2
Tx: d/c Amlodipine, Enoxaparinstart Diltiazem, Dabigatran
Cardio: MGH (11/12); follow up OPD
Neuro: MGH (11/13); follow up OPD
Take Home Medications
Generic Name Brand Name Dose Administration Indication
Dipyridamole Persantine 200 mg / tab BIDAntiplatelet. Thromboxane and Phosphodiesterase inhibitor
ASA 80 mg / tab OD Antiplatelet. COX inhibitorDabigatran Pradaxa 110 mg / tab BID Anticoagulant. Direct thrombin II inhibitor
Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMD Imdur 60 mg / tab OD Nitro-vasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 Blocker
Insulin Glargine Lantus 42 Units OD, SQ Antidiabetic. Long-acting insulin analogue
Sitagliptin Januvia 50 mgOD,
pre-breakfast Antidiabetic. Secretagogue, DPP-4 inhibitor
Diltiazem Dilzem 30 mg / tab TID Antiarrhythmic. Calcium Channel blockerAtorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLCo-Amoxiclav Amoclav 625 mg / tab TID till 11/19 Antibiotic. Penicillin + Beta-lactamase inhibitorCiticoline Zynapse 1 g /tab BID Nootropic. Psychostimulant
Levetiracetam Keppra 500 mg / tab BID AnticonvulsantPhenytoin Dilantin 100 mg / cap TID Anticonvulsant, Antiarrhythmic. Sodium channel blocker.
Case Discussion
Pathophysiology Video
Epileptogenesis
• Transformation of a normal neuronal network into one that is chronically hyperexcitable
• Trauma, stroke, or infection• Injury lowers the seizure threshold in the
affected region
• CVD is the number one cause of epilepsy in the elderly• Oxfordshire Stroke Community Project (OSCP)
– 11.5% of patients with stroke are at risk of developing late-onset post-stroke seizures within 5 years
• Naess and colleagues– 10.5% developed post-stroke seizure over mean follow up
of 5.7 years.• Hart and colleagues
– recurrence after a first seizure after stroke of 40% in 12 months
Early Onset Seizure• occurs w/in first two
weeks• peak 24 hrs after stroke
Late Onset Seizure• occurs after two weeks of
stroke onset• peak 6-12 months after
stroke
• associated with the persistent changes in neuronal excitability and gliotic scarring
• Cortical location – Best-characterized risk
factor for early seizures after ischemic stroke
– Significant risk factor in the SASS study (HR, 2.09; 95% CI, 1.19 to 3.68; P<0. 01)
• Stroke severity – Independently associated
with the development of seizures after ischemic stroke (HR, 10; 95% CI, 1.16 to 3.82; P<0.02)
Seizures and Epilepsy After Ischemic StrokeOsvaldo Camilo and Larry B. Goldstein, 2004
Management
• Antiepileptic Drug Therapy– Goal: completely prevent seizures without
causing untoward side effects
• Treat the underlying conditions– Reverse the problem and prevent its
recurrence
What is the drug of choice for adults with generalized-onset tonic–clonic
seizures?Patient’s Medications Upon Admission
• Phenytoin (Dilantin) 100mg/cap TID
ILAE Treatment Guidelines:
• Effectiveness-outcome evidence– Based on RCT efficacy and
effectiveness evidence, CBZ, LTG, OXC, PB, PHT, TPM, and VPA are possibly efficacious/effective as initial monotherapy for adults with GTC seizures and may be considered for initial therapy in selected situations (level C) (Glauser, et al. 2006)
Glauser, Tracy, Elinor Ben-Menachem, Blaise Bourgeois, and et. al. "ILAE Treatment Guidelines: Evidence-based Analysis of Antiepileptic Drug Efficacy and Effectiveness as Initial Monotherapy for Epileptic Seizures and Syndromes." (Internationl League Against Epilepsy) 27, no. 7 (2006): 1094 -1120.
Were these maintenance medications necessary?
• Maintenance since Jan 2010, post stroke– ASA
80mg/tab OD
– Dipyridamole (Persantine) 200mg/tab BID
• International Stroke Trial (IST, Lancet 1997;349:1569-1581)– Aspirin treated patients had slightly fewer deaths at 14 days,
significantly fewer recurrent ischemic strokes at 14 days and no excess of hemorrhagic strokes
• Dipyridamole for Preventing Stroke and Other Vascular Events in Patients With Vascular Disease: An Update 2008– Compared with control, dipyridamole had no clear effect on
vascular death (RR 0.99, 95% CI, 0.87 to 1.12). – Compared with control, dipyridamole appeared to reduce the
risk of vascular events (RR 0.88, 95% CI, 0.81 to 0.95). – Routine use of dipyridamole alone as first line antiplatelet
treatment is not supported. The combination of dipyridamole plus aspirin is associated with a lower risk of further vascular events than aspirin alone.
What maintenance medications does this patient need?
• Home Medications– Citicoline 1gm/tab BID– ASA 80 gm/tab OD– Levetiracetam 500mg
tab BID– Phenytoin 100mg/cap
TID
Public Health Perspective
The Philippine Scenario
• The statistics are grim– Less than half of hypertensive patients are
aware that they have high blood pressure– Only about 1/4th are taking antihypertensive
medications– Only about 10 percent or less have
adequately controlled high blood pressure.• Filipinos trivialize Hypertension
Castillo, Dr. Rafael. Stroke Prevention Campaigns. Philippine Daily Inquirer, 2007.
Complications After Stroke Deprive Patients of Years of Optimum Health
• Researchers used data on patients enrolled in the Complication in Acute Stroke Study (COMPASS) (n=1254)
• Average DALYs lost due to a stroke was 3.82• The more complications the patient
experienced, the more DALYs lost – 1 complication – 1.52 more DALYs lost– 2 or more complications – 2.69 more DALYs lost
A U.S. National Institutes of Health and the American Heart Association funded study, July 2010
AWARENESS CAMPAIGNS
I-Stroke Campaign http://www.otsuka.com.ph/istroke/