case files neurology
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case files neurology


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especially beneficial for patients who have gait difficulty or
aphasia, or who require assistance in activities of daily living or help resum-
ing gainful employment after a stroke.
The treatment of hemorrhagic stroke is primarily supportive and involves
control of hypertension. Intracranial pressure should be monitored and
addressed with hyperventilation and osmotic therapy, or surgical decompres-
sion when appropriate. Thrombolytic therapy is contraindicated.
Comprehension Questions
[11.1] An 81-year-old patient arrives in the emergency department with acute
left hemiparesis and neglect. What finding is most important in deter-
mining noneligibility for thrombolytic treatment?
A. Time of symptom onset of 2 hours
B. History of any previous myocardial infarction
C. Patient taking any antihypertensive medication
D. Recent gastrointestinal (GI) bleeding
[11.2] For this patient in question 11.1, what study is most useful to rule out
an intracerebral hemorrhage?
A. Electrocardiogram
B. Brain CT
C. Complete blood count
D. Cerebral arteriogram
[11.3] After receiving stroke therapy, the patient is being discharged home on
physical therapy. The usual treatment would include long-term
antiplatelet treatment; however, it is not used in this patient\u2019s case.
Which of the following is most likely to be present such that antiplatelet
therapy is not prescribed?
A. The patient has diabetes
B. The patient has ischemic heart disease
C. The patient has carotid stenosis
D. The patient has atrial fibrillation
100 CASE FILES: NEUROLOGY
Answers
[11.1] D. A history of bleeding issues can contraindicate the use of an
anticoagulant.
[11.2] B. The head CT scan is reliable and rapid in assessing for cerebral
hemorrhagic stroke.
[11.3] D. When atrial fibrillation is present, then warfarin therapy is used
rather than antiplatelet therapy.
CLINICAL CASES 101
CLINICAL PEARLS
\u2756 Sudden onset of focal neurologic deficits equals stroke until proven
otherwise.
\u2756 Time is brain viability; treat ischemic stroke with thrombolytics within
3 hours to preserve brain tissue.
\u2756 Stroke risk factors are similar to those of ischemic heart disease.
\u2756 Cortical symptoms suggest a carotid territory stroke; brainstem or
cerebellar findings suggest a vertebrobasilar territory stroke.
REFERENCES
Mohr JP, Choi D, Grotta J, et al. pathophysiology, diagnosis, and management,
4th ed. Churchill Livingstone; 2004.
Ropper AH, Brown RH. Adams and Victor\u2019s principles of neurology, 8th ed. New
York: McGraw-Hill; 2005.
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\u2756 CASE 12
A 50-year-old female is brought by her husband to the Emergency Center after
experiencing sudden onset of severe headache associated with vomiting, neck
stiffness, and left-sided weakness. She was noted to complain of the worst
headache of her life shortly before she became progressively confused. Two
weeks ago she returned from jogging noting a moderate headache with nausea
and photophobia. She has a history of hypertension and tobacco use. On exam-
ination, her temperature is 37.6°C (99.8°F); heart rate, 120 beats/min; respira-
tion rate, 32 breaths/min; and blood pressure, 180/90 mmHg. She is stuporous
and moaning incoherently. Her right pupil is dilated with papilledema and ipsi-
lateral ptosis, and she vomits when a light is shone in her eyes. She has a left
lower face drooped and does not withdraw her left arm and leg to pain as
briskly compared to the right. Her neck is rigid. Her chest examination reveals
tachycardia and bibasilar crackles. During the examination, her head suddenly
turns to the left, and she exhibits generalized tonic-clonic activity. STAT labo-
ratory tests show a sodium level of 125 mEq/L. The electrocardiograph (ECG)
shows prolonged QT interval and T-wave inversion.
\u25c6 What is the most likely diagnosis?
\u25c6 What is the next diagnostic step?
\u25c6 What is the next step in therapy?
ANSWERS TO CASE 12: Subarachnoid Hemorrhage
Summary: A 50-year-old female with a history of hypertension and tobacco
use presents with sudden onset of the worse headache of her life associated
with confusion, vomiting, neck stiffness, and left-sided weakness. She was
noted to complain of a headache 1 week ago. She is now hypertensive. Her
neurologic examination is significant for stupor, right cranial nerve III paraly-
sis, left-sided weakness, neck stiffness, and a seizure. Her workup is signifi-
cant for hyponatremia and ECG changes.
\u25c6 Most likely diagnosis: Subarachnoid hemorrhage
\u25c6 Next diagnostic step: Noncontrast CT of the head
\u25c6 Next step in therapy: Cerebral angiography
Analysis
Objectives
1. Identify the epidemiology and risk factors for subarachnoid hemorrhage.
2. Understand the prognosis and complications of subarachnoid
hemorrhage.
3. Know a diagnostic and therapeutic approach to subarachnoid
hemorrhage.
Considerations
This 50-year-old woman has multiple risk factors for subarachnoid hemor-
rhage caused by an underlying aneurysm, including her age (mean age for
subarachnoid hemorrhage is 50 years of age), sex (slightly higher risk for
females), hypertension, and tobacco use. The complaint of \u201cthe worst
headache of my life\u201d to describe its sudden severe onset is classic, and may or
may not be associated with altered mentation and focal neurologic deficits.
There is usually a history of a recent moderate headache as a result of sentinel
bleed, as in her case after running, and 60% of subarachnoid hemorrhages
occur during physical or emotional strain, head trauma, defecation, or coitus.
The clinical severity of the subarachnoid hemorrhage is graded based on the
degree of stupor, nuchal rigidity, focal neurologic deficits, and elevation of
intracranial pressure. Our patient exhibits neurogenic pulmonary edema, a rare
complication of subarachnoid hemorrhage. Her neurologic signs localize to a
ruptured right posterior communicating artery aneurysm, with the bleed caus-
ing compression of the nearby ipsilateral cranial nerve III with mydriasis, pto-
sis, and impaired extraocular movements. Her contralateral hemiparesis and
complex partial seizure with secondary generalization can result from either
parenchymal extension of the hemorrhage with edema or middle cerebral
104 CASE FILES: NEUROLOGY
artery vasospasm, all three of which are complications of subarachnoid hem-
orrhage. Hyponatremia is frequently seen on chemistries, correlating with an
elevation of atrial natriuretic factor, cerebral salt wasting, and syndrome of
inappropriate antidiuretic hormone. ECG changes, especially QT prolonga-
tion, T-wave inversion, and arrhythmias, are also systemic complications com-
mon to subarachnoid hemorrhage.
APPROACH TO SUBARACHNOID HEMORRHAGE
Definitions
Subarachnoid space: The spongy interval between the arachnoid mater and the
pia mater. The headache and nuchal rigidity is caused by chemical inflam-
mation of the pia arachnoid from blood degradation products in this space.
Sentinel bleed: Intermittent aneurysmal subarachnoid hemorrhage causing
lesser headaches that precede the \u201cworst headache\u201d that occurs with rup-
ture of the aneurysm.
Vasospasm: Most alarming complication of aneurysmal subarachnoid hem-
orrhage in which irritation causes constriction of major cerebral arteries,
vasospasm lethargy, and cerebral infarction. Vasospasm occurs mostly
with aneurysms rather than other causes of subarachnoid hemorrhage, and
peaks after 4 to 14 days. Transcranial Doppler can be used to detect a
change in flow velocity in an affected middle cerebral artery.
Acute communicating hydrocephalus: Complication that occurs because
of obstruction of the subarachnoid granulations in the venous sinuses by
the subarachnoid blood. CT shows enlarged lateral, third, and fourth
ventricles, with clinical signs of headache, vomiting, blurry and double
vision,