A 68-year-old woman with an unknown medical history was brought to the ED after she was found unconscious on the sidewalk. Bystanders called 911, and EMS reported that she was awake but nonverbal and unresponsive to commands.
The patient was awake and alert on arrival in the ED but still nonverbal. Her initial vital signs were a blood pressure of 191/106 mm Hg, a temperature of 36.7°C, a pulse of 85 bpm, a respiratory rate of 24 bpm, and an oxygen saturation of 100% on room air. An exam showed no evidence of head or musculoskeletal trauma, and her cardiopulmonary exam was normal. A neurological exam demonstrated that she could open her eyes on command, and she could look to the left but not the right. She exhibited significant strength deficits in her right arm and leg. Her pupils were 2 mm and reactive. No spasticity of the right arm or leg was found, and her initial NIHSS score was 19.
Paramedics reported that no alcohol or drug paraphernalia were found on the scene, nor was a wheelchair or walking assist device. The patient was found on a well-traveled pedestrian walkway that likely wouldn't have been without foot traffic for more than 15-30 minutes at a time. What is her diagnosis?
Find the diagnosis and case discussion on p. 23.
Diagnosis: MCA Stroke
The patient's physical exam was most consistent with an ischemic stroke. A stroke code was activated after the initial assessment, and she was emergently brought for a noncontrast head CT and CTA of the head and neck. The patient vomited after the scan, and was intubated with rapid sequence intubation for airway protection. Representative noncontrast and CTA images were consistent with no bleed and an acute large, left-sided middle cerebral artery (MCA) stroke. (See photo.)
Large vessel stroke syndromes can be devastating to patients. Any patient with stroke-like symptoms should be evaluated using the NIHSS and when she was last known well. (See the table for a list of large vessel stroke symptoms.)
Patients who experience large hemispheric anterior circulation strokes may be candidates for intra-arterial mechanical thrombectomy if the facility at which they present is a stroke center with that expertise. Current American Heart Association recommendations suggest that a patient who presents within six hours of symptom onset and meets the criteria is a candidate for mechanical thrombectomy. (Stroke 2015;46:3020; http://bit.ly/2RMWqsF.) The patient must meet these criteria:
- Clinical diagnosis of acute stroke
- Minimal pre-stroke disability
- NIHSS ≥6 points or persistent deficit considered disabling
- ASPECTS score >6 (normal noncontrast CT brain=10, diffuse ischemic change=0)
- Brain CT or MRI to rule out hemorrhage
- Occlusion of ICA or proximal MCA (M1) demonstrated with imaging
- Age 18 or older
Two recent trials have shown benefit of mechanical thrombectomy at more than six hours from when the patient was last known well (LKW). The DEFUSE 3 trial enrolled patients with ischemic stroke between six to 16 hours from LKW and found that thrombectomy along with standard medical therapy was superior to standard therapy alone. (N Engl J Med 2018;378:708; http://bit.ly/2RNqepe.) The DAWN trial also enrolled patients six to 24 hours from LKW and found better outcomes with thrombectomy plus standard of care compared with standard of care alone. (N Engl J Med 2018;378:11; http://bit.ly/2RIRViS.)
Given the clinical picture, CTA results, and stroke team evaluation, the patient was brought in for emergent left MCA thrombectomy. A hyperacute MRI was deferred because she had metal artifact in her skull from previous trauma. After the procedure, the patient's exam improved to only residual mild dysphagia and dysarthria with some right arm and leg drift. Transthoracic echo was unrevealing. She was discharged within a week with an NIHSS score of 3 (1 for right arm drift, 1 for right leg drift, and 1 for facial weakness).
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