general data
DESCRIPTION
General Data. DS 65 year old Female Informants : Patient and Husband Reliability Patient 70% Husband 80 % Right- handed. Chief Complaint. “Numbness of the left hand”. History of Present Illness. Nine months PTA, “pins and needles” sensation; left hand - PowerPoint PPT PresentationTRANSCRIPT
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General Data
• DS• 65 year old• Female• Informants: Patient and Husband• Reliability
– Patient 70%– Husband 80%
• Right- handed
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Chief Complaint
• “Numbness of the left hand”
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History of Present Illness
• Nine months PTA,– “pins and needles” sensation; left hand– one episode of generalized tonic- clonic seizure
• Head tilting to the right• Eyes rolling upward• Stiffening of upper and lower extremities• Tongue biting• Lasting for 1- 2 minutes
– (-) blurring of vision, palpitations, tremors, nausea, vomiting, dizziness, sweating, urinary incontinence
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History of Present Illness• Admitted in the hospital for 10 days
– CT scan was done– Discharge summary: Seizure. Two old right
parietal lobe hemorrhagic infarcts. Hypertension. Diabetes Mellitus Type II. Hypercholesterolemia.
– Medications prescribed: • Aspirin 75 mg OD• Dipyridamole 200 mg OD• Perindopril 8 mg OD
– No memory of what happened– Patient was able to go back to work
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History of Present Illness
• One hour PTA, – (+) inward movement and numbness of the
left hand– (+) disorientation and confusion– (+) stiffness of truncal extremity– (+) rapid and incoherent speech
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History of Present Illness
• At the ER,– Two episodes of generalized tonic- clonic
seizures similar to the one in January• 30 minutes apart
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History of Present Illness
• At the ACSU– throbbing headache located on the top of her
head,(6/10)– (+) generalized weakness– (-) memory of what happened
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Review of Systems
• Neurologic: (-) history of gait imbalance, frequent headaches
• General: (-) fever, weight loss, easy fatigability• HEENT: (-) tinnitus, colds, epistaxis, otorrhea• Respiratory: (-) difficulty of breathing, coughing• Cardiovascular: (-) chest pains, orthopnea, PND• Gastrointestinal: (-) change in bowel movements,
abdominal pain, melena, hematochezia
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Review of Systems
• Genitourinary: (-) dysuria, frequency, incontinence, tea colored urine
• Endocrine: (-) heat or cold intolerance, excess thirst, excess sweat, polydipsia, polyuria
• Musculoskeletal: (-) joint pain and swelling • Dermatologic: (+) dermatoses/ trophic skin
changes
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Past Medical History
• Illnesses– Angina 2007 maintained on ISMN (Imdur) 60 mg tab
OD– Hypertension maintained on Bisoprolol 10 mg OD and
Perindopril 8 mg OD– DM Type II 2000 maintained on Insulin glargine
(Lantus) 40 mg SQ OD– Hypercholesterolemia 2000 maintained on Atorvastatin
20 mg/ tab OD• (-) Trauma• (-) History of febrile seizures
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Past Medical History
• Surgeries: None• Hospitalization: January 2010• Allergies: No known allergies
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Past Medical History
• Ob- gyne– G3P3(3003) – LMP 55 years old– (+) OCP use for 6 months; 1981 (36 yo)– (-) hormone replacement therapy– (+) preeclampsia: third pregnancy– (+) blood transfusion: third pregnancy
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Medications
• Compliant with:
1) Aspirin 75 mg OD
2)Dipyridamole 200 mg/ tab OD
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Family Medical History
• Diabetes• Hypertension• Breast Cancer• Stroke• Cardiovascular disease
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Personal and Social History
• Married with three children • Occupation: nurse• Occasional drinker• Non- smoker
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Physical Examination
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Physical Examination
• Awake, not in cardiorespiratory distress• Height: 165 cm• Weight: 80 kg• BMI = 34• BP = 160/70• HR = 73• RR = 14• T = 36.5OC
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Physical Examination
• HEENT– Anicteric sclerae; pink palpebral conjunctiva– No nasal congestion– Moist buccal mucosa– (-) cervical lymphadenopathy, tonsillopharyngeal congestion,
enlarged thyroid gland– non- distended neck veins, (-) carotid bruit
• Respiratory– Symmetric chest expansion– No retractions– Clear breath sounds
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Physical Examination• Cardiovascular
– Adynamic precordium– Apex beat at 5th ICS LMCL– Regular rhythm, normal rate– Distinct S1 at apex and S2 at base– (-) Murmurs
• Abdominal– Flabby, soft abdomen– Normoactive bowel sounds– No tenderness– No organomegaly
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Physical Examination
• Extremities– Full and equal pulses (2+)– (-) edema– Good skin turgor
• Skin– Normal hair and scalp, nails– Trophic skin changes/ dermatoses– No pallor or jaundice
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Physical Examination• Neuro examination at the ER:
– Awake, confused and disoriented, able to follow some verbal commands; GCS 14
– Intact cranial nerves– Intact sensory– Motor
• Minimal spasticity on the left. • Left arm can lift 30˚.
– Supple neck– (+) Babinski reflex, L
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Neurologic Examination• GCS 15 • Mental Status Exam:
– Cooperative towards examiner– Awake, alert with intact attention span– Euthymic with appropriate affect– Non- spontaneous, normoproductive speech– No perceptual disturbances– Goal oriented with normal thought content– Oriented to time, place and person– Intact memory and calculation– Good fund of information– Good insight and judgment– (-) agnosia, apraxia
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Neurologic Examination– Cranial Nerves
• I – Not done• II – Pupils 3mm, equally reactive to light; visual fields full to
confrontation• III, IV, VI – Full EOM’s• V – Corneal reflex not done, sensory- intact bilaterally in all
three divisions for sharp, dull, touch stimuli; motor- temporal and masseter strength intact
• VII – No facial weakness and asymmetry• VIII – Gross hearing intact• IX, X – (+) gag reflex• XI- (+) shoulder shrug, head turn, 5/5• XII – tongue at midline
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Physical Examination• Neurologic
– Motoro (-) muscle, involuntary movementso 5/5 on all extremities except for left upper extremity (4/5)o Drift on the upper left extremityo DTRs: ++ on bilateral brachioradialis, biceps, triceps, patellar and
ankle; (-) Babinski– Somatic
o 100% touch/pain on all extremities. Temperature sensation intact bilaterally and symmetrically. Position sense intact bilaterally and symmetrically intact except for left upper extremity
– Cerebellaro No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel
along shin intact bilaterally)– Supple neck, (-) Brudzinski, Kernig's
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Initial Impression
• Epileptic seizure
• R/o space- occupying lesion vs. CVD
• Hypertension Stage II
• Diabetes Mellitus Type 2
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Differential Diagnoses
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Syncope
Rule In Rule OutLoss of consciousness
-LOC and GTC movements <15-30 seconds- Loss of postural tone-Rare tongue biting and headache
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Transient Ischemic Attack
Rule In Rule Out-Focal neurologic deficit-altered consciousness -Presence of risk factors
- Generalized seizures
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Neoplastic
Rule In Rule Out
-Family history of cancer-Focal neurologic deficit
-Slowly decreasing level of consciousness-No weight loss, nausea, vomiting, irritability
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Infection
Rule In Rule Out
Seizures -No fever, nausea, vomiting, irritability-Supple neck, (-) Kernig's and Brudzinski
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Stroke
Rule In Rule Out
-Headache, confusion, lapse of consciousness-(+) hypertension, diabetes mellitus-(+) Risk factors of hypertension, diabetes mellitus
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Hypoglycemia
Rule In Rule Out- seizure-Confusion-Headache-History of insulin use
- Diaphoresis- Pallor- Dizziness- Blurred or double vision
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Subarachnoid Hemorrhage
Rule In Rule Out- focal neurologic deficit- altered level of conciousness/confusional state
-Severe headache at onset, may be with neck stiffness and vomiting-Generalized seizures
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Initial Imaging Studies
• Head CT– Wedge shaped I'll defined hypodense focus is
seen in the cortical subcortical region of the right parietal lobe.
– Underlying gyrus and sulci are effaced. – Patchy hypodensities along the periventricular
white matter of both frontal and parietal lobes are also noted.
– The rest of the grey-white matter interface is maintained.
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Initial Diagnostics
• CT– Malacic changes
• CBC– Hgb 138– Hct .42– WBC 8.5
• N .72• L .24• M .04
– PC 137
• PT 12.2• INR 0.89• ALT 27.04• BUN 4.48• Creatinine 99.01• Na 137• K 3.9• Lipid Profile (results to follow)
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Initial Management
• Phenytoin– Loading dose 1gm– Maintained at 100 mg/cap TID
• Admit to ACSU– Cardiac, CBG monitoring– O2 Support, seizure precautions
• Diazepam 5 mg IV• Ketorolac 30 mg IV then q8 prn for headache• Continue maintenance medications
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Day 1 -3 (Nov 7-9)
S O A PNo recurrence of seizureSome difficulty sleeping
GCS 15Stable vitalsClear breath sounds NRRR, distinct S1/S2Soft abdomen
CBG=256 mg/dL
Post-stroke seizureHypertensionDM 2
Dx:MRI, MRA, MRV (Nov 8 )Tx:Citicoline Insulin glulisine
Possible discharge Nov. 11
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Imaging Results
• Cranial MRI– Wedge-shaped Right inferior parietal cortical-
subcortical encephalomalacia, gliosis and siderosis, presumably sequelae of a previous water-shed type infarction with hemorrhagic conversion
– Mild microvascular white matter ischemic changes on the left centrum semiovale
– Mild central cerebral volume loss
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Imaging Results
• MRA: No aneurysm or any significant stenosis or vascular malformations seen
• MRV: No evident cortical vein or dural sinus thrombosis
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Day 4 (Nov 10)
S O A P
Asymptomatic: (-) palpitations, chest pain, dizziness
Atrial Fibrillation in RVR recorded for 3 hours (3:40 am)
Paroxysmal AF Dx: 12L ECGTx: BisoprololCardio referral
Cardio: BP 116 / 77HR 52Sinus bradycardiaGood S1, NRRR (-) carotid bruit
Paroxysmal AF, now back in sinusHypertension, stage 2
Dx: 2D ECHO TFTsTx: Amlodipine, Enoxaparin,Clonidine,ISMN
Neuro:No recurrence of seizures
MRI/MRA/MRVCholesterol 3.75 (3.4 – 5.2)HDL 2.33 (high)LDL 1.39Triglycerides 0.93vLDL 0.42
Post Gliotic SeizureCVD infarct, Right MCA
Tx: Levetiracetam, Sitagliptin
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Diagnostics
• ECG: Atrial Fibrillation, RVR• TFT:
– TSH 3.01 uIU/mL– FT3 2 pg/mL– FT4 0.83 ng/dL
• EEG: abnormal EEG due to a focal theta slowing on the right temporo-parietal occipital region with wave epileptiform discharges on the right temporo-occipital region consistent with a focal cerebral dysfunction and a tendency toward localization-related seizures at the right temporo-occipital region
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Day 5-7 (Nov 11-13)
S O A P
Neuro/Cardio:AsymptomaticComfortableNo recurrence of AF, seizures
GCS 15Stable vitalsClear breath sounds NRRR, distinct S1/S2Soft abdomen
Post-Gliotic SeizureParoxysmal AFHypertensionDM 2
Tx: d/c Amlodipine, Enoxaparinstart Diltiazem, Dabigatran
Cardio: MGH (11/12); follow up OPD
Neuro: MGH (11/13); follow up OPD
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Take Home Medications
Generic Name Brand Name Dose Administration Indication
Dipyridamole Persantine 200 mg / tab BIDAntiplatelet. Thromboxane and Phosphodiesterase inhibitor
ASA 80 mg / tab OD Antiplatelet. COX inhibitorDabigatran Pradaxa 110 mg / tab BID Anticoagulant. Direct thrombin II inhibitor
Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMD Imdur 60 mg / tab OD Nitro-vasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 Blocker
Insulin Glargine Lantus 42 Units OD, SQ Antidiabetic. Long-acting insulin analogue
Sitagliptin Januvia 50 mgOD,
pre-breakfast Antidiabetic. Secretagogue, DPP-4 inhibitor
Diltiazem Dilzem 30 mg / tab TID Antiarrhythmic. Calcium Channel blockerAtorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLCo-Amoxiclav Amoclav 625 mg / tab TID till 11/19 Antibiotic. Penicillin + Beta-lactamase inhibitorCiticoline Zynapse 1 g /tab BID Nootropic. Psychostimulant
Levetiracetam Keppra 500 mg / tab BID AnticonvulsantPhenytoin Dilantin 100 mg / cap TID Anticonvulsant, Antiarrhythmic. Sodium channel blocker.
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Case Discussion
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Pathophysiology Video
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Epileptogenesis
• Transformation of a normal neuronal network into one that is chronically hyperexcitable
• Trauma, stroke, or infection• Injury lowers the seizure threshold in the
affected region
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• CVD is the number one cause of epilepsy in the elderly• Oxfordshire Stroke Community Project (OSCP)
– 11.5% of patients with stroke are at risk of developing late-onset post-stroke seizures within 5 years
• Naess and colleagues– 10.5% developed post-stroke seizure over mean follow up
of 5.7 years.• Hart and colleagues
– recurrence after a first seizure after stroke of 40% in 12 months
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Early Onset Seizure• occurs w/in first two
weeks• peak 24 hrs after stroke
Late Onset Seizure• occurs after two weeks of
stroke onset• peak 6-12 months after
stroke
• associated with the persistent changes in neuronal excitability and gliotic scarring
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• Cortical location – Best-characterized risk
factor for early seizures after ischemic stroke
– Significant risk factor in the SASS study (HR, 2.09; 95% CI, 1.19 to 3.68; P<0. 01)
• Stroke severity – Independently associated
with the development of seizures after ischemic stroke (HR, 10; 95% CI, 1.16 to 3.82; P<0.02)
Seizures and Epilepsy After Ischemic StrokeOsvaldo Camilo and Larry B. Goldstein, 2004
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Management
• Antiepileptic Drug Therapy– Goal: completely prevent seizures without
causing untoward side effects
• Treat the underlying conditions– Reverse the problem and prevent its
recurrence
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What is the drug of choice for adults with generalized-onset tonic–clonic
seizures?Patient’s Medications Upon Admission
• Phenytoin (Dilantin) 100mg/cap TID
ILAE Treatment Guidelines:
• Effectiveness-outcome evidence– Based on RCT efficacy and
effectiveness evidence, CBZ, LTG, OXC, PB, PHT, TPM, and VPA are possibly efficacious/effective as initial monotherapy for adults with GTC seizures and may be considered for initial therapy in selected situations (level C) (Glauser, et al. 2006)
Glauser, Tracy, Elinor Ben-Menachem, Blaise Bourgeois, and et. al. "ILAE Treatment Guidelines: Evidence-based Analysis of Antiepileptic Drug Efficacy and Effectiveness as Initial Monotherapy for Epileptic Seizures and Syndromes." (Internationl League Against Epilepsy) 27, no. 7 (2006): 1094 -1120.
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Were these maintenance medications necessary?
• Maintenance since Jan 2010, post stroke– ASA
80mg/tab OD
– Dipyridamole (Persantine) 200mg/tab BID
• International Stroke Trial (IST, Lancet 1997;349:1569-1581)– Aspirin treated patients had slightly fewer deaths at 14 days,
significantly fewer recurrent ischemic strokes at 14 days and no excess of hemorrhagic strokes
• Dipyridamole for Preventing Stroke and Other Vascular Events in Patients With Vascular Disease: An Update 2008– Compared with control, dipyridamole had no clear effect on
vascular death (RR 0.99, 95% CI, 0.87 to 1.12). – Compared with control, dipyridamole appeared to reduce the
risk of vascular events (RR 0.88, 95% CI, 0.81 to 0.95). – Routine use of dipyridamole alone as first line antiplatelet
treatment is not supported. The combination of dipyridamole plus aspirin is associated with a lower risk of further vascular events than aspirin alone.
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What maintenance medications does this patient need?
• Home Medications– Citicoline 1gm/tab BID– ASA 80 gm/tab OD– Levetiracetam 500mg
tab BID– Phenytoin 100mg/cap
TID
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Public Health Perspective
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The Philippine Scenario
• The statistics are grim– Less than half of hypertensive patients are
aware that they have high blood pressure– Only about 1/4th are taking antihypertensive
medications– Only about 10 percent or less have
adequately controlled high blood pressure.• Filipinos trivialize Hypertension
Castillo, Dr. Rafael. Stroke Prevention Campaigns. Philippine Daily Inquirer, 2007.
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Complications After Stroke Deprive Patients of Years of Optimum Health
• Researchers used data on patients enrolled in the Complication in Acute Stroke Study (COMPASS) (n=1254)
• Average DALYs lost due to a stroke was 3.82• The more complications the patient
experienced, the more DALYs lost – 1 complication – 1.52 more DALYs lost– 2 or more complications – 2.69 more DALYs lost
A U.S. National Institutes of Health and the American Heart Association funded study, July 2010
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AWARENESS CAMPAIGNS
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I-Stroke Campaign http://www.otsuka.com.ph/istroke/
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