LONG CASE

A 30-year-old male electrician by occupation from Nakrekal came to the hospital with chief complaints of weakness in the right upper limb and right lower limb since 15 months

Difficulty while speaking since 15 months

History of present illness:    

Patient was a 30 year old electrician who used to climb up the cell towers for repair works

Born in the middle order with one elder brother & one younger brother

His daily routine include waking up at 7-8 am and going to work at 9am after having breakfast and returning home at 6-7 pm after a tiring work for 7-8 hrs

Married at the age of 25 yrs and has 2 children and used to live happily with his family & friends

But 15 months back his whole life was turned upside down when he developed sudden onset weakness in right upper limb & lower limb with mouth deviation to left side due to which he was not able to do his daily work of living & earning and he became dependant on family members

Patient was apparently asymptomatic 15 months back and then he developed weakness in the right upper limb and right lower limb which was sudden in onset and associated with on and off difficulty in speech.

Weakness was predominantly on the right arm than the right leg.

History of difficulty in speaking since 15 months - patient describes it as not able to  tell what he wants to tell but able to write it down (word-finding pauses)

History of difficulty in buttoning the shirt, mixing the food, and writing present

History of slippage of footwear present

No difficulty in squatting and getting up from the squatting position, climbing stairs up and down

There was no diurnal variation of weakness

No difficulty in lifting the head off the pillow

No difficulty in rolling over the bed, getting up from the bed

No difficulty in breathing

No history of  pain or muscle cramps or fasciculations and any involuntary movements

Able to feel clothes, feeling hot and cold water while bathing

No history of tingling, numbness, pricking-like sensation, band like sensation or sensation of walking on cotton wool

No history of neck pain, or back pain

No history of unsteadiness on closing his eyes and is able to walk in the dark

No history of loss of consciousness or alteration in sensorium or any bowel bladder involvement. 

No history of Delusions/ Hallucinations/emotional disturbances

No history of alteration of smell, blurring of vision, diplopia, difficulty in chewing, hearing difficulties or dysphagia.

No history of giddiness, syncope, sweating, or palpitations 

No history of bowel or bladder incontinence

No history of fever, headache, vomiting, or neck stiffness.

No history of calf pain, trauma, fall from height, or any drug intake.


Past history: 

No history of similar complaints in the past.

No comorbid illness like Diabetes Mellitus, Hypertension, coronary artery disease, thyroid disease, HIV, Tuberculosis, malignancy, or surgeries.


Personal history: 

Married And non-vegetarian with normal sleep and appetite.

No alcohol and smoking habits.

Regular bowel & bladder habits


Family history: 

Nonconsanguinous marriage, With no similar complaints in the family.


No significant past treatment history.


Summary:

Onset: Acute                                                          

Progression: rapidly progressive                          

Neurological: Right hemiparesis with UMN-type facial Nerve involvement

Anatomical:  cortex > subcortical                                                     

Etiology: secondary to vascular > inflammatory.


General examination:

Patient conscious, coherent, and oriented to time place person       

Moderately built and nourished                                                                                                                   

No pallor, icterus, clubbing, koilonychia, lymphedema, and pedal edema.

Temperature: Afebrile                                                  

PR: 78 bpm, regular, normal in volume and character with no radio radial delay or radio femoral delay. 

BP: 130/80 mm hg in the right and left arms.

RR: 16 CPM     







Systemic examination:

Central nervous system:

Higher mental functions: 

Level of Conscious Normal (GCS: 15/15)

Oriented to time place and person.

Speech and language : 

spontaneous speech present 

Comprehension present 

Fluency absent

Repetition absent

Reading and writing present 


Cranial Nerve Examination: 

1st Cranial Nerve (Olfactory): 

Sense of smell present 

2nd Cranial Nerve (Optic): 

Visual acuity, Field of vision, and color vision are present. Fundus is normal.

3rd,4th, and 6th cranial Nerves (Oculomotor, Trochlear, Abducens): 

Extraocular movement   And pupil size normal

Direct and indirect light reflexes present and  accommodation reflex present

No ptosis and nystagmus

5th cranial Nerve (Trigeminal): 

Sensations over the face present

Corneal conjunctival reflex present

7th Cranial Nerve (Facial): 

Motor: Nasolabial fold absent on the right side 

Orbicularis occuli and frontalis muscle normal

Tongue Sensations Normal

Corneal and conjunctival reflexes present


8th Cranial Nerve (Vestibulo-Cochlear): 

Rinnes test and Weber test- No hearing loss.

9th and 10th cranial Nerve (Glossopharyngeal and Vagus): 

Uvula and Palatal arch movements are normal and the gag reflex is present.

11th cranial Nerve (Spinal accessory): 

Sternocleidomastoid and trapezius muscle normal

12th Cranial Nerve (Hypoglossal): 

Tongue protrusion in the midline.


Gait: Hemiplegic circumduction gait




Motor System: 

Bulk: 

Inspection: Right thigh appears to be atrophied

Measurements:

Upper limb: 

Right side 27.5 cms @ 10 cms above the olecranon & 24 cms @ 10 cms below the olecranon 

Left side 29.5 cms @ 10 cms above the olecranon & 26 cms @ 10 cms below the olecranon 

Lower limb: 

Right side 46 cms @ 18 cms above the superior border of patella & 33 cms @ 10 cms below the tibial tuberosity

Left side 50 cms @ 18 cms above the superior border of patella & 33 cms @ 10 cms below the tibial tuberosity


                              Right.               Left

Tone: 

 Upper limb.      Normal           Normal

 Lower limb.      Normal           Normal


Power:

Upper limb:           

   Proximal muscles    4/5                5/5   

        Deltoid 

        Supraspinatus 

         Infraspinatus 

        Biceps

         Triceps

    Brachioradialis

    Pectoralis and latismus 

Dorsi muscle

Rhomboidus


Distal muscles.     0/5               5/5       

ECR

ECU

Extensor digitorum

FCR 

FCU        

            

Lower limb:           

Proximal muscles      4/5                   5/5

 Iliopsoas

 Adductor femoris

Gluteus maximus

Gluteus medius and 

minimus

Hamstrings

Quadriceps femoris


Distal muscles.                0/5                    5/5

Tibialis anterior

Tibialis posterior

EDL

FDL

EHL

EDB


Reflexes:                       Right          Left

Superficial reflexes 

Corneal reflex.           Present.      Present

Conjunctival reflex.    Present.     Present

Abdominal reflex.      Present       Present 

Plantar reflex.             Extensor.     Flexor


Deep tendon reflexes

Biceps.                       +++.             +

Triceps.                       +++.            +

Supinator.                   +++             +

Knee.                          +++.             +

Ankle.                          +++             +

BICEPS

TRICEPS


SUPINATOR


KNEE



ANKLE


PLANTAR




Sensory system:

Spinothalamic tract:  touch, pain, and temperature sensations are normal

Posterior column: vibration, position, and fine touch normal.

Cortical sensations: Graphaesthesias and stereognosis absent.


No cerebellar signs.


Cardiovascular system:

S1, S2 heard

No murmurs


Respiratory system:

Bilateral air entry and Normal vesicular breath sounds were heard.


Per abdomen:

Soft and no organomegaly


Provisional diagnosis: 

Cerebrovascular accident: Right-sided hemiparesis with Right UMN type of facial Palsy with Broca's aphasia secondary to left MCA territory involvement


Investigations: 

Hemogram: 

Hb: 15.7 gm/dl                                                      

TLC: 8,800 cells/cumm.                                                     

Platelets: 3.1 lakhs/cumm 


RBS: 103mg/dl


LFT: 

Total bilirubin: 0.64 mg/dl

Direct bilirubin : 0.18mg/dl 

Total proteins:6.9

Albumin: 4.39


RFT: 

Serum creatinine: 1.0 mg/dl

Blood urea:18mg/dl

Serum electrolytes: Normal

Fasting lipid profile: Normal


ESR: 20mm/hr  

CRP: negative


APTT:34 sec

Bleeding time:2 min 30sec

Clotting time:4 min 30sec


D Dimer: 300 ug

RA factor:  negative


CUE:

Albumin: Trace

Sugar: Nil

Pus cells:2-3cells/HPF

Epithelial cells:2-3cells/HPF


HIV: Non-Reactive

HbsAg: Non-reactive

VDRL: Negative


ECG:

12 lead ECG at 25 mm/sec showing sinus rhythm with regular RR interval with normal p wave QRS complex and T wave morphology


2d ECHO: 

Normal LV systolic function

No regional wall motion abnormalities

EF: 62%


Chest x-ray :


Cxray PA views the inspiratory and non-rotated film.

Domes of the Diaphragm are clearly seen and well defined with no cardiomegaly

The right heart border and left heart border are clear with no Hilar lymphadenopathy or any Lymph node enlargement.

Bones and ribs appear normal.


MRI brain : 




Final diagnosis: 

Cerebrovascular accident: Right-sided hemiparesis with Right UMN type of facial Palsy with Broca's aphasia secondary to ischemic stroke involving left insula, temporal and front parietal regions (left MCA territory)


Treatment:        

Physiotherapy of the right upper limb and lower limb.



Discussion: 

Ischaemic stroke in young: 

Definition: 

Many authors consider the age of 45 years as the upper limit for stroke in young.

Epidemiology:  

About 10-15% of strokes occur in younger patients, constituting approximately 2 million adolescents and young adults worldwide who suffer from an ischaemic stroke.

Risk factors:

Conventional risk factors like Diabetes Mellitus, Hypertension, and dyslipidemia.

Risk factors for stroke in young include smoking, alcohol, and drug abuse: cocaine IV drug users, and oral contraceptive pills. 

Migraine with aura, Malignancy

Etiology:

1) Cardiac causes: 

30% of stroke in young is secondary to cardiac causes: Congenital heart disease, PFO,

Atrial fibrillation, Acute MI, cardiomyopathy, Endocarditis, Cardiac tumors like atrial myxoma

2) Noninflammatory Nonatherosclerotic causes: 

Arterial dissection, Marfans, Radition vasculopathy, Migraine, Fibromuscular dysplasia, CADASIL.

3) Inflammatory:

Takayasu arteritis, Giant cell arteritis, Kawasaki disease, PAN, Churg Strauss, Wegner, microscopic Polyangiitis.

4) Infections: 

HIV, Tuberculosis, Hepatitis B, syphilis

5) Hypercoagulable states: 

Protein C, protein S and antithrombin III deficiency, APLA, hyperhomocysteinemia, factor v leiden mutation, Sickle cell.


Approach to stroke in young: 

CLINICAL CLUE

SUSPICION

Fever

Infection
Connective tissue disease
Vasculitis

Lymphadenopathy

Lymphoma
Infection

History of asthma

Churg Strauss syndrome

History of recent head trauma

Arterial dissection
In situ arterial thrombosis

Headache

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
(CADASIL)
Arterial dissection
Vasculitis
Systemic lupus erythematosus (SLE)

Oral/genital ulcers

Syphilis
SLE
Behçet disease
Herpes simplex

Butterfly erythema

SLE

Splinter hemorrhages underneath the nail

Endocarditis

 

Needle puncture signs

Drug use

Tattoos

HIV infection
Hepatitis

Alopecia

Systemic lupus erythematosus (SLE)
Temporal arteritis
Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL)

Xanthelasma

Hyperlipidemia


Investigations:

First-line investigations: 

CBC, Lft, Rft, ECG, CXR, peripheral smear, ESR, CRP, HIV serology CT, MRI scan 2decho

Second-line investigations:

MR angiography, RA factor, serum homocysteine levels, protein C, protein S, Anca levels, factor V, Holter monitoring, D Dimer levels.


Treatment:  

Treatment depends on the etiology of the stroke and once etiology is identified then treatment is individualized.

Antiplatelets are given.


Rehabilitation after stroke is a multidisciplinary approach with physiotherapists, occupational therapists, and speech-language therapists.


https://www.intechopen.com/chapters/72380

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