Case #4

Gerarld Immanuel Kairupan

 60 year old female, with a history of heart bypass 10

years PTA, on irregular intake of aspirin, suddenly developed right sided weakness and slurring of speech, few mins PTA. On PE: BP 150/90 PR 80/min RR 20/min, Pupils 4 mm EBRTLS, GCS 13 (E3V3M6), verbally aphasic but can follow some commands, with right hemiplegia Head CT Scan done showed no abnormal findings

Pertinent Data
History
60 year old Female Heart bypass 10y PTA Irregular intake of aspirin

Right sided weakness and slurring of speech few

mins PTA

Pertinent Data
PE
Hypertensive (150/90) GCS V-3(inappropriate words) Verbally aphasic, can follow some commands R hemiplegia

Imaging
Head CT Scan no abnormal findings

 Aphasia reflects damage to

one or more of the brain's primary language centers, which, in most people, are located in the left hemisphere. Broca's area lies next to the region of the motor cortex that controls the muscles necessary for speech. Wernicke's area is the center of auditory, visual, and language comprehension. Connecting Wernicke's and Broca's areas is a large nerve bundle, the arcuate fasciculus, which allows repetition of

 Wernicke's Aphasia
Wernicke's aphasia is caused by damage to the side

portion or temporal lobe of the language-dominant area of the brain

People with serious comprehension difficulties have

what is called Wernickes aphasia and:

Often say many words that dont make sense. (speak

in long, uninterrupted sentences; however, the words used are frequently unnecessary or even made-up) They may be unable to understand other people's speech. Reading ability is diminished, and although writing ability is retained, what is written may be abnormal. No physical symptoms, such as the right-sided weakness seen with Broca's aphasia, are typically observed.

 Broca's Aphasia motor aphasia

Injury to the left frontal area can lead to what is called Brocas

aphasia.
Survivors with Broca's aphasia:
Individuals with Broca's aphasia may either be completely unable

to use speech (mutism) or they may be able to use single-word statements or even full sentences. However, these sentences are construct with great difficulty. May get out some basic words to get their message across, but leave out words like is or the. Often say something that doesnt resemble a sentence. Can make mistakes in following directions like left, right, under, and after. Carbumpboom! This is not a complete sentence, but it certainly expresses an important idea. Sometimes these individuals will say a word that is close to what they intend, but not the exact word; for example they may say car when they mean truck. Hearing comprehension is usually not affected, so they are able to understand other people's speech and conversation and can follow commands. Often, weakness on the right side of their bodies makes it difficult

 Global Aphasia
When a stroke affects an extensive portion of the front and

back regions of the left hemisphere, the result may be global aphasia. As a result, all basic language functionsare affected, but some areas may be more affected than others. For example,an individual may have difficulty speaking but may be able to write well.
Survivors with global aphasia:
May have great difficulty in understanding words and

sentences. May have great difficulty in forming words and sentences. May understand some words. Get out a few words at a time. Have severe difficulties that prevent them from effectively communicating. The individual may experience weakness and loss of feeling

Differential Diagnosis
Occlusive Cerebrovascular disease

secondary to Cardioembolism Occlusive Cerebrovascular disease secondary to Atherothrombotic Disease Antiphospholipid syndrome Multiple Sclerosis

Embolic Infarction

Most common cause of stroke Occur in late adult life Embolic strokes are also ischemic strokes. Any region of the brain may be affected
Middle cerebral artery, particularly the superior division, is the

most frequently involved.

Caused by blockage of one of the arteries to the brain by a

blood clot that has formed elsewhere (usually in the heart), broken free, and traveled to the brain as an embolus. Sometimes the clot can form in the aorta, which is the largest artery in the body. These clots can travel to any artery in the brain, but more often they block the larger arteries, causing more severe strokes. Embolic strokes can cause any of the typical symptoms of ischemic stroke.

High risk for cardiac causes

Atrial fibrillation and paroxysmal atrial fibrillation (most

common cause) Rheumatic disease of the mitral or aortic valve disease Artificial heart valves Known cardiac thrombus of the atrium or ventricle Sick sinus syndrome Sustained atrial flutter Recent myocardial infarction Chronic myocardial infarction together with ejection fraction <28 percent Symptomatic congestive heart failure with ejection fraction <30 percent Dilated cardiomyopathy Libman-Sacks endocarditis Marantic endocarditis Infective endocarditis,papillary fibroelastoma Left atrial myxoma

Clinical Picture
Most rapidly develop compare to other type of stroke

(abrupt in onset) Lack of prodromal symptoms Neurologic picture will depend on the artery involved and the site of obstruction Common signs of stroke include the following:
Acute hemiparesis or hemiplegia Acute hemisensory loss Complete or partial hemianopia, monocular or binocular

visual loss, or diplopia Dysarthria or aphasia Ataxia, vertigo, or nystagmus Sudden decrease in consciousness

Atherothrombotic Infarct
In thrombotic stroke a thrombus (blood clot)

usually forms around atherosclerotic plaques. Slower onset (since blockage of the artery is gradual) A thrombus itself (even if non-occluding) can lead to an embolic stroke if the thrombus breaks off, at which point it is called an "embolus."

 Two types of thrombosis can cause stroke:

Large vessel disease involves the common

and internal carotids, vertebral, and the Circle of Willis.

Diseases that may form thrombi in the large vessels include

(in descending incidence): atherosclerosis, vasoconstriction (tightening of the artery), aortic, carotid or vertebral artery dissection, various inflammatory diseases of the blood vessel wall (Takayasu arteritis, giant cell arteritis, vasculitis), noninflammatory vasculopathy, Moyamoya disease and fibromuscular dysplasia
Small vessel disease involves the smaller arteries

inside the brain: branches of the circle of Willis, middle cerebral artery, stem, and arteries arising from the distal vertebral and basilar artery.

 The most frequent sites of atheromatous plaques are

found in the
internal carotid artery, at its origin from the common

carotid cervical part of the vertebral arteries and at their junction to form the basilar artery stem or at the main bifurcation of the middle cerebral arteries posterior cerebral arteries as they wind around the midbrain anterior cerebral arteries as they curve over the corpus callosum

Risk Factor
Although atheromatosis is known to have its onset in

childhood and adolescence, only in the middle and late years of life is it likely to have clinical effects Hypertension Hyperlipidemia Diabetes Low high-density-lipoprotein (HDL) cholesterol High low-density-lipoprotein (LDL) cholesterol Long-duration cigarette smoking, an important factor in the genesis of atherosclerosis, decreases both HDL cholesterol and cerebral blood flow Possible role of an excess of homocystine and a speculative role for chronic inflammation, particularly with Chlamydia pneumoniae Clinical experience indicates that there are families with a predilection for the development of cerebral

Clinical Picture
more variable than that of embolism and

hemorrhage In more than half of patients, the main part of the stroke (paralysis or other deficit) is preceded by TIAs
A history of such prodromal episodes is of

paramount importance in establishing the diagnosis of cerebral thrombosis.

Vascular disease in other parts of body

Antiphospholipid syndrome
Overview of Disease
Antiphospholipid syndrome is a disorder in which

immune system mistakenly produces antibodies against certain normal proteins in the blood. Antiphospholipid syndrome can cause blood clots to form within the arteries or veins as well as pregnancy complications, such as miscarriages and stillbirths. Antiphospholipid syndrome may lead to the formation of blood clots in the legs, a condition known as deep vein thrombosis (DVT). Antiphospholipid syndrome may also cause blood clots to form in organs, such as your kidneys or lungs. Damage depends on the extent and location of the clot.
For instance, a clot in the brain can cause stroke

 Risk Factors
Autoimmune condition, such as lupus or Sjogren's

syndrome, increases risk of developing antiphospholipid antibodies. Infections, such as syphilis or hepatitis C. Certain medications, such as hydralazine for high blood pressure. Family History

It's possible to have the antibodies associated with antiphospholipid syndrome without ever developing signs or symptoms. However, if a person have these antibodies, the risk of developing blood clots increases particularly if:
Become pregnant Remain immobile for a period of time (such as sitting during

a long airline flight) Undergo surgery Smoke cigarettes Have high blood pressure or high cholesterol Take oral contraceptives

 Sign and Symptoms

Blood clots in the legs (deep vein thrombosis, or DVT) that may

travel to lungs (pulmonary embolism) Repeated miscarriages or stillbirths and other complications of pregnancy, such as premature delivery and high blood pressure during pregnancy (preeclampsia) Stroke

Other less common signs and symptoms include:

Neurological symptoms. Chronic headaches, including

migraines, dementia and seizures are possible when a blood clot blocks blood flow to parts of your brain. Rash. Some people develop a red rash with a lacy, net-like pattern (livedo reticularis) on the wrists and knees. Cardiovascular disease. Heart valve problems are common among people with antiphospholipid syndrome. Heart valves open and close to keep blood flowing through heart's four chambers in only one direction. Typically, the mitral valve develops masses or thickens, which can cause blood to leak backward through it (regurgitation). The aortic valve also may be affected. Bleeding. Some people experience a decrease in platelets. If platelet count drops too low, patient may have episodes of

Multiple Sclerosis
Overview of Disease
Multiple sclerosis (MS) is a potentially debilitating

disease in which body's immune system eats away at the protective sheath (myelin) that covers the nerves. Among the most venerable of neurologic diseases and one of the most important by virtue of its frequency, chronicity, and tendency to attack young adults. It is characterized clinically by episodes of focal disorder of the optic nerves, spinal cord, and brain, which remit to a varying extent and recur over a period of many years

 Risk Factors
Age. Multiple sclerosis can occur at any age, but most

commonly affects people who are ages 20 to 40. Gender. Women are about twice as likely as men to develop multiple sclerosis. Family history. Certain infections. Epstein-Barr virus and other viruses, appear to be associated with multiple sclerosis. Ethnicity. White people, particularly those whose families originated in northern Europe, are at highest risk of developing multiple sclerosis. Geographic regions. Multiple sclerosis is far more common in areas such as Europe, southern Canada, northern United States, New Zealand and southeastern Australia. Other autoimmune diseases. Person may be slightly more likely to develop multiple sclerosis if they have thyroid disease, type 1 diabetes or inflammatory bowel

 Signs and Symptoms

Symptoms vary widely, depending on the amount of

damage and the nerves that are affected. People with severe cases of multiple sclerosis may lose the ability to walk or speak clearly. Diagnosis may be uncertain at the onset and in the early years of the disease, when symptoms and signs point to a lesion in only one locus of the nervous system. Later, as the disease recurs and disseminates throughout the cerebrospinal axis, diagnostic accuracy approaches 100 percent Classic features include motor weakness, paraparesis, paresthesias, impaired vision, diplopia, nystagmus, dysarthria, intention tremor, ataxia, impairment of deep sensation, and bladder dysfunction.