an unusual cause of stroke in young 21 st may
TRANSCRIPT
![Page 1: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/1.jpg)
An unusual cause of stroke in young
Presenter :Dr. T. Ashok V ReddyPost graduate
BMCRIVICTORIA HOSPITAL
![Page 2: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/2.jpg)
25 Yr old female From Banswadi area ,Bengaluru. Presented with complaints of sudden onset
loss of speech , weakness of right side upper and lower limbs and face from early morning after she woke up.
Presenting complaints and History
![Page 3: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/3.jpg)
Early morning she woke up and found that she was unable to speak.
After 30 minutes ,she observed weakness of right upper and lower limbs and right face .
No history of seizures ,fever , headache, bladder and bowel disturbances.
Not a diabetic,not a hypertensive.No H/o abortions.
![Page 4: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/4.jpg)
GENERAL PHYSICAL EXAMINATION- Pallor present VITALS : PR-90/min,regular in rhythm Peripheral pulses- Right side radial artery –Felt Left side brachial ,radial -Feeble Bilateral femoral ,popliteal ,dorsalis
pedis artery pulsations –Feeble No features suggestive of gangrene in limbs.
EXAMINATION
![Page 5: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/5.jpg)
BP : Right upper limb -110/80 mm Hg Left upper limb and bilateral lower limbs –
not recordable Bruit heard over left carotid artery Respiratory rate -14/min Temp – 37.2celsius
![Page 6: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/6.jpg)
Neurological examination- Motor aphasia present Right sided UMN facial nerve palsy
Right sided hemiplegia (Power 0/5), Right side hypotonia, Deep tendon reflexes –Right side 1+ Left side 2+ sensory system –normal cerebellar system could not be tested. Fundus examination -normal
![Page 7: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/7.jpg)
CVS-S1 and S2 present No murmurs.RS and abdominal examination – normal
OTHER SYSTEMS
![Page 8: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/8.jpg)
Hb-8.1g/dl MCV-61.5 Fl MCH-16.8 pg Platelet count-3 lakh/micro L
ESR-10mm at the end of 1hr Random blood sugar-105 mg/dL LFT –Albumin-3.5g/dL ALP-120 U/l
INVESTIGATIONS
![Page 9: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/9.jpg)
T.Bilirubin-0.6mg/dL Globulin-4.3g/dL AST-21 U/L ALT-14 U/L Total protein-7.8g/dL
RENAL FUNCTION TESTS- Urea -15mg/dL Creatinine-0.6mg/dL
![Page 10: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/10.jpg)
C reactive protein –positive HBs ag ,RA- negative VDRL,HIV –non reactive CT Brain – Normal
ANA profile –negative Serum homocysteine-10 micro mol/l Serum B12 levels-500pg/ml Sputum for AFB negative
![Page 11: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/11.jpg)
![Page 12: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/12.jpg)
![Page 13: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/13.jpg)
![Page 14: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/14.jpg)
ECG and ECHO Cardiography – normal Neck vessel doppler – Right side:Circumferential wall thickening of common carotid artery ,external carotid and internal carotid artery causing luminal narrowing. Left side: Circumferential wall thickening of
Common carotid ,internal and external carotid artery thickening causing near total occlusion.
Above features were suggestive of arteritis.
![Page 15: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/15.jpg)
AORTO ARTERITIS Points in favour – young age , Feeble pulse in extremities except right upper limb.
Possible diagnosis
![Page 16: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/16.jpg)
Tuberculosis Syphilis Takayasu disease Irradiation Rheumatic fever Ankylosing spondylitis
Causes of Aorto arteritis
![Page 17: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/17.jpg)
1 Age at onset of disease<40 yrs. 2 Claudication of extemities. 3 Decreased brachial artery pulse. 4 BP difference >10 mmHg between arms. 5 Bruit over subclavian artery /aorta 6 Arteriogram abnormality .
If atleast 3 of above criteria are present ,diagnosis can be made with 90 % sensitivity and 97 % specificity .
ACR Criteria for diagnosis of Takayasu arteritis
![Page 18: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/18.jpg)
Diagnosis of Takayasu arteritis was made. Steroids were started . Tab .Predisolone 40 mg per day . Tab.Aspirin 150 mg od
After 1 week ,power improved to 3/5 in right upper limb and to 4 /5 in lower limb.
![Page 19: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/19.jpg)
No H/O claudication /fatigue /discomfort in limbs before the weakness developed.
No H/O fever,weight loss,myalgia,arthralgia.
No rise of imflammatory markers like ESR
.
Unusual features in this case
![Page 20: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/20.jpg)
Described by Adams in 1827. In 1908 Takayasu described a wreath like
appearance of arterio venous anastamosis around optic papilla.
2 stages- Early active phase Chronic sclerotic phase.
Takayasu arteritis
![Page 21: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/21.jpg)
Diminished /absent pulses in 84-96% Bruit over carotid/subclavian artery/aorta in
80-90% Hypertension in 33 -83% Retinopathy in 37 % Aortic regurgitation in 20-25% Pulmonary artery involvement in 14-100 % Neurological features like
headache,TIA,seizures in 10-20% 3.2 % present as ischemic stroke
Clinical features
![Page 22: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/22.jpg)
Takayasu arteritis is rare disease which affects mainly women .
Manifestations range from asymptomatic disease to catastrophic neurological impairment.
The four most important complications are Takayasu retinopathy, secondary hypertension, aortic regurgitation, and aneurysm formation which have to be monitored intermittently at least once in 6 months.
Conclusion
![Page 23: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/23.jpg)
Approximately half of those patients treated with steroids will respond, remaining patients respond to methotrexate; mycophenolate mofetil.
Treatment should aim to control disease activity and preserve vascular competence.
Fertility is not adversely affected and pregnancy does not appear to exacerbate the disease, although management of hypertension is essential.
![Page 24: An unusual cause of stroke in young 21 st may](https://reader035.vdocuments.us/reader035/viewer/2022062420/55c2927ebb61eb6e2b8b47d0/html5/thumbnails/24.jpg)
References
Harrison’s text book of internal medicine,18th edition.
API Text book of medicine Monogram on vasculitis by
Dr.G.Narasimhulu. Gamboa R, et al. DNA sequencing of HLA-B
alleles in Mexican patients with Takayasu arteritis. Int J Cardiol 2000;75:S117–22.