Mrs Oswald is a 78-year-old female who presents to the emergency department with a 2-hour history of slurred speech. She also complains of difficulty with word-finding and right-sided weakness and numbness. She denies any vision changes, headache, fever, trauma, chest pain, or abdominal pain. She has a history of hypertension, hyperlipidemia, and atrial fibrillation. Her medications include hydrochlorothiazide, metoprolol, fish oil, and aspirin. She has not taken warfarin for the last 3 years after an incident of diverticular bleeding. She does not smoke or use alcohol. On examination, she is awake yet anxious, with a blood pressure of 194/102 mm Hg, heart rate of 116 bpm, respiratory rate of 20 breaths/min, and oxygen saturation of 96% on room air. Chest auscultation reveals clear lungs and an irregularly irregular rhythm. Abdominal examination reveals a soft, nontender abdomen and normal bowel sounds. Neurological examination reveals expressive aphasia, left facial droop, right-sided sensory deficits, and right-sided motor strength of 3/5. Left arm and leg sensory and motor examination are normal.
Lab data show hemoglobin 12.6, hematocrit 38, WBCs 10,600, and platelets 186,000. Basic metabolic panel is normal. Point-of-care glucose is 109. CT scan of the head is normal.
1. What is the most likely diagnosis?
2. What is the most likely cause of this new diagnosis?
3. What else should be considered in the differential diagnosis?
This is a 78-year-old with risk factors for stroke (age, hypertension, hyperlipidemia, atrial fibrillation) who presents with sudden stroke-like symptoms. Her vital signs reveal compensatory measures being taken by the body. Her normal head CT scan has ruled out an acute hemorrhage.
Her stroke is most likely embolic in nature, related to not being on anticoagulation for the atrial fibrillation.
Other potential diagnoses to consider include complex migraine headache, tumor or mass, and toxic-metabolic abnormalities. This case allows for a discussion of acute stroke, including types, presenting signs and symptoms, and management.
Strokes are the result of ischemia or hemorrhage of affected brain tissue. They are the leading cause of adult disability in the United States and the second leading cause of death worldwide. Risk factors include elderly age, hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, previous stroke or transient ischemic attack, and cigarette smoking.
Ischemic stroke and hemorrhagic stroke are the 2 major categories. Eighty percent to 90% of strokes are ischemic in nature.
Ischemic strokes are due to 4 main causes: arterial thrombosis, embolism, hypoperfusion, and venous thrombosis. Arterial thrombosis is usually in the setting of atherosclerosis, but may also be seen with arterial dissection or vasculitis. Arterial embolism typically arises in the heart, such as in the setting of atrial fibrillation, left ventricular thrombus, or infective endocarditis. Hypoperfusion seen in the setting of such disease states ...