76 year old female presents to your OPD with 3 hours history of weakness of right hand, headache and problem with her vision.

  76 year old female presents to your OPD with 3 hours history of weakness of right hand, headache and problem with her vision.

She also complains of lightheadedness, numbness and tingling on right arm and leg , and difficulty with her speech.

You take her BP which is found to be high at 160/89 mmHg.

She is also having a severe headache that has not responded to analgesics.

You suspect the patient could be having stroke in evolution and decide to order a CT scan of head and ECG and send bloods for further investigations.

Her CT scan is given below:

What are the findings in the CT scan.

Why do you want to conduct/ organize and ECG?

Which bloods should you send?

What is the most likely Diagnosis?

How would you manage this patient?

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Answers given in comments section.

1. What are the findings in the CT scan. 

The CT of the head is showing a left occipital infarct. Infarct are visible as dark opacities on CT scan without contrast . 

This is a CT scan without contrast. CT images are conventionally viewed from below,as if looking up into the top of the head. 

This means the right side of the brain is on the left side of the viewer. So as you look at the axial CT images, your left is the patients right side. 

So the right side of the image depicts the left side of the patient. Hence in this case , the occipital appears to be on the right side of the viewer but actually its showing the left side of patient , so the Occipital infarct is on the left side of the patients brain.

2. Why do you want to conduct/ organize and ECG? 

We need to mak sure the patient is not having a disturbed / irregular rhythm / atrial fibrillation as it can lead to development of cardiac thrombi and lead to stroke / cerebral infarcts.

3. Which bloods should you send? 

It is vital to determine underlying cause of stroke , most common on which include cardiac causes, diabetes mellitus, 

Hyoercholesterolemia and hypertension. 

Bloods should be sent for Full blood count , CRP ( to determine underlying sepsis ) sugar levels , Lipid profile, urea, creatinine, and clotting profile , INR < PT , APTT , Proteic C and S levels , Factor V leiden mutations to exclude pro thrombotic diseases and lups antic coagulant. Other investigations.

4. What is the most likely Diagnosis? 

Most likely diagnosis is acute occipital infarct / CVA

5. How would you manage this patient? 

Since it has been less than 4.5 hours and patient is developing an acute infarct , she should be managed by thrombolysis once exclusions of haemorrhage on neuro imaging has been done. 

The drug of choice is Alteplase : 

ALTEPLASE DOSING FOR ACUTE ISCHAEMIC STROKE

 0.9mg / kg body weight to maximum of 90mg

 10% total dose should be given as initial iv bolus

 remainder (90%) should be infused iv over 60 mins in 0.9% sodium

chloride (or can be given neat via a syringe pump).