22: 70-year-old male with new-onset unilateral weakness

Question 1

Due to this risk, the United States Preventive Services Task Force recommends:

Answer 1

ALL adults >18 yrs be screened for hypertension

Adults > 20 yrs should be screened for hyperlipidemia if at increased risk for CAD (i.e., diabetic, hypertensive, premature personal history of atherosclerosis or family history of CAD in males < 50 yrs or females < 60 yrs)

All adults be asked about tobacco use, and all smokers be given tobacco cessation interventions.

Clinicians should discuss aspirin chemoprevention with all men over 45 for primary prevention of myocardial infarction.

Question 2

Orthostasis

Answer 2

A reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who has accommodated to the supine position assumes a standing or sitting position.

Some experts also consider the test to be positive when the pulse rate remains increased by 20 beats per minute or more (16 beats per minute in the elderly).

Question 3

afib

Answer 3

is rapid, irregular, and chaotic atrial activity without definable p waves on electrocardiogram. Its presence should be suspected in individuals presenting with dizziness, syncope, dyspnea, or palpitations. While palpation of an irregular pulse or auscultation of an irregular heart rate may raise suspicion of atrial fibrillation, the diagnosis requires confirmation with electrocardiogram.

Question 4

afib epi

Answer 4

Atrial fibrillation (AF) is the most common arrhythmia physicians face in clinical practice, accounting for about one- third of hospitalizations for arrhythmia. The prevalence of AF increases with age and the severity of congestive heart failure or valvular heart disease. Furthermore, in most cases, AF is associated with the cardiovascular diseases of hypertension, coronary artery disease, cardiomyopathy, and mitral valve disease. Pulmonary disorders of COPD, obstructive sleep apnea, and pulmonary embolism are associated and predisposing factors. Other associated conditions include surgery, excess alcohol intake, hyperthyroidism, and febrile illnesses.

Question 5

Distinguishing persistent vs. paroxysmal afib

Answer 5

Atrial fibrillation less than 72 hours total duration would be classified as new onset. Chronic atrial fibrillation may be either persistent or paroxysmal. In the paroxysmal form, atrial fibrillation may recur and then revert back to normal rhythm spontaneously, with variable periods of normal sinus rhythm between episodes. The presence of normal rhythm does not rule out the existence of paroxysmal atrial fibrillation. This arrhythmia can occur episodically without clinical detection or significant symptoms for several months.

Question 6

Cardiovascular or Cerebrovascular Mechanisms:

Answer 6

1.Embolic
Most commonly from the heart or carotid artery– arrhythmias may produce emboli from mural thrombi, atrial appendages, or from diseased heart valves

2.Thrombotic
Native clot within the intracranial vasculature – 85% of strokes are caused by vascular occlusion (thrombotic)

3.Cardiogenic
Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation

4.Hemorrhagic
Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.

Question 7

Hematologic and Vascular Mechanisms:

Answer 7

Hematologic:
Hyperviscosity or myleoproliferative syndromes (polycythemia, leukemias, or thrombocytosis), vascular obstruction (sickle cell anemia), severe anemia and conditions associated with hypercoagulable states (lupus anticoagulant or antiphospholipid antibody; presence of Factor V Leiden; or deficiencies of protein C, protein S, or antithrombin III).

Vascular mechanisms:
Hypertension leading to thrombosis or bleeding, atherosclerotic emboli from carotid or vertebral plaques, extrinsic compression of cranial vessels (cervical osteophytes, or rotational kinking, tumor), vasospasm (migraine, cocaine) and vasculitis.

Question 8

TIA Symptoms Preceding Stroke

Answer 8

Individuals experiencing TIA symptoms have been shown to have an 8% to 12% chance of having a stroke within one week and an 11% to 15% chance of having a stroke within one month.

Question 9

Evaluation of a Patient with Suspected Ischemic Stroke

Answer 9

Time is crucial in evaluation of a patient with suspected ischemic stroke because if given within three hours, intravenous t-PA has proven benefit in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given within six hours.

Question 10

Although it is desirable to know the results of these tests before giving recombinant tissue Plasminogen Activator (rtPA), thrombolytic therapy should not be delayed while awaiting the results unless:

Answer 10

1. there is clinical suspicion of a bleeding abnormality or thrombocytopenia
2. the patient has received heparin or warfarin
3. use of anticoagulants is not known

Question 11

AF with Rapid Ventricular Response (RVR) is the presence of physiologic or non-physiologic (electrical) ventricular tachycardia in the presence of AF.

Answer 11

Etiology
Fever, myocarditis, pericarditis, volume contraction, thyrotoxicosis, endogenous catecholamines, and AV nodal dysfunction are causative.

Complications
In the presence of a diminished cardiac output at baseline, AF with RVR predisposes to hemodynamic instability, functional impairment, heart failure and ischemia.

Treatment
»Rate control: Controlling the heart rate with intravenous diltiazem, beta-blockers, or verapamil improves
blood flow and does not delay immediate need for emergency stroke treatment.
»Rhythm control: Cardioversion either via electric shock to the heart with the patient under sedation or via medications given orally or intravenously. Both methods carry a risk of stroke which is greatest in patients who have had atrial fibrillation for more than 48 hours, or who have not been given three weeks of prior anticoagulant therapy.

Question 12

Symptoms of Right Parietal Infarct

Answer 12

Right-hand dominant patients with strokes in the area of the brain are likely also to have left hemiplegia. Patients with right middle cerebral infarcts affecting the right parietal hemisphere may have difficulties with their spatial and perceptual abilities, which causes them to misjudge distances, or they may attempt to read holding books upside down. They may ignore people or objects in their left visual field or not pay attention to that area of the room. They may also not recognize their functional impairments (denial of stroke disability).

Question 13

Stroke Symptoms of Other Regions:

Answer 13

Strokes that occur in the brain stem would likely be the cause of respiratory impairment and affect vital functions of blood pressure, heartbeat and consciousness.

Expressive and receptive aphasia and right facial weakness are classically associated with a left middle cerebral artery stroke.

A central nerve injury such as a stroke often spares involvement of the portion of the facial nerve that controls the forehead. This is because there is bilateral central control of this portion of the facial nerve.

A peripheral injury to the facial nerve (such as Bell’s Palsy) causes facial weakness of the forehead.

Question 14

Basic activities of daily living (BADLs)

Answer 14

Bathing
Dressing and undressing
Eating
Transferring from bed to chair, and back Voluntarily control urinary and fecal discharge Using the toilet
Walking (not bedridden)

Question 15

Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but enable the individual to live independently within a community

Answer 15

Light housework
Preparing meals
Taking medications
Shopping for groceries or clothes 
Using the telephone
Managing money

Question 16

Coronary Heart Disease and Stroke in African Americans

Answer 16

African Americans have the highest rates of coronary heart disease (CHD) of any ethnic group in America, and stroke mortality rates are strikingly high in this population group in general.

Question 17

Post-Stroke Depression - Epidemiology, Definition, Cause, Complications, Management

Answer 17

Epidemiology
One third of stroke survivors experience post-stroke depression.

Definition
DSM 5 defines this the occurrence of a mood disorder judged to be due to the direct physiological effects of another medical condition.

Cause
The precise cause of depression following stroke is unknown and its development is thought to be due to multiple factors which include lesion location, individual adjustment to disability, and levels of family or social support.

Complications
Untreated post-stroke depression can impede rehabilitation progress and lead to impaired functional outcome, cognitive decline, and increased mortality.

Management
SSRIs are accepted first-line therapy and have been proven to improve clinical outcomes in suffers of post-stroke depression. Selection of a particular SSRI is guided by the potential for drug-drug interactions and patient tolerance.

Question 18

Initial Physical Exam of Neurologic Symptoms

Answer 18

Exam of cranial nerve VII
Facial asymmetry is not specific for stroke as it can also be caused by Bell’s Palsy or Horner’s syndrome. Weakness or asymmetry of the muscles of facial expression (CN VII) is a common presenting sign of stroke.

Auscultation of carotids
Listen for carotid bruits as emboli from carotid arteries are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.

Romberg
Ischemic blood flow in the vertebrobasilar system is associated with ataxic gait and instability of balance that may be revealed with Romberg testing.

Cardiopulmonary
The presence of murmurs or irregular rhythms on thecardiovascular exam may signal valvular disease and intra-cardiac mural thrombi as sources for cardiac emboli.

Gross visual fields
Emboli from carotid bruits are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.

Proprioception
Proprioceptive and spatial deficits are present in patients who have suffered brain ischemia affecting the sensory areas.

Mental status exam & assessment of motor strength
Documentation of mental status to include the level of alertness, orientation, comprehension (both receptive and expressive) and memory are essential, as are tests of gross motor strength and coordination.

12 lead electrocardiogram
An electrocardiogram can detect abnormalities of QT interval, conduction abnormalities, and ST changes suggestive of paroxysmal arrhythmia or myocardial ischemia producing transient central nervous system hypoperfusion.

Question 19

Pronator Drift

Answer 19

The pronator drift is one of the most sensitive tests for upper extremity weakness.

The patient is asked to flex their arms 90 degrees at the shoulders, supinate their forearms, close their eyes, and hold the position. If a forearm pronates, then the patient is said to have pronator drift on that side.

Question 20

Face Arm Speech (FAST) Test

Answer 20

used by ambulance paramedics and physicians for the rapid clinical assessment of patients with suspected transient ischemic or stroke symptoms.

Question 21

Prevention of a First Stroke

Answer 21

1. Adjusted-dose warfarin (target INR, 2.0-3.0)
   Recommended for all patients with nonvalvular AF deemed to be at high risk and many deemed to be at moderate risk for stroke who can receive it safely (Class I; Level of Evidence A).
2. Antiplatelet therapy with aspirin
   Recommended for low-risk and some moderate-risk patients with AF on the basis of patient preference, estimated
   bleeding risk if anticoagulated, and access to high-quality anti​coagulation monitoring (Class I; Level of Evidence A).
3. Dual-antiplatelet therapy with clopi​dogrel and aspirin
   Offers more protection against stroke than aspirin alone but with an increased risk of major bleeding and might be reasonable f or high-risk patients with AF deemed unsuitable for anticoagulation (Class IIb; Level of Evidence B).

Question 22

Prevention of Stroke in Patients With a History of Stroke or TIA

Answer 22

1. For patients with ischemic stroke or TIA with parox​ysmal (intermittent) or permanent AF
   Anticoagulation with a vitamin K antagonist (target INR, 2.5; range, 2.0-3.0) is recommended (Class I; Level of
   Evidence A).
2. For patients unable to take oral anticoagulants
   As​pirin alone (Class I; Level of Evidence A) is recom​mended. The combination of clopidogrel plus aspirin carries a risk of bleeding similar to that of warfarin and therefore is not recommended for patients with a hemorrhagic contraindication to warfarin * (Class III; Level of Evidence B).

Question 23

New Alternative Antithrombotic Agents for Stroke Prevention in Patients With AF

Answer 23

Warfarin (Class I; Level of Evidence A), dabigatran (Class I; Level of Evidence B), apixaban (Class I; Level of Evidence B), and rivaroxaban (Class IIa; Level of Evidence B) are all indicated for the pre​vention of first and recurrent stroke in patients with nonvalvular AF.

The selection of an antithrom​botic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in INR therapeutic range if the patient has been taking warfarin.

Question 24

CHADS2 Score for Atrial Fibrillation Stroke Risk

Answer 24

The CHADS2 score is a validated instrument that applies known cardiovascular risk factors to provide calculated guidance to help weigh the benefits and risks of anticoagulation. A new version of the CHADS2, the CHA2DS2-VASc, is currently being evaluated.

Certain types of stroke are associated with an increased risk of intracranial hemorrhage at the site of the infarct with early anticoagulation. Current guidelines recommend delaying starting anticoagulation.

Question 25

HL

Answer 25

All patients with a history of TIA or CVA should be placed on high-intensity statin such as atorvastatin 40 or 80 mg or rosuvastatin 20 mg.  Class I, Level A

Question 26

HTN

Answer 26

Antihypertensive treatment is recommended for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke and are beyond the hyperacute period. Recent guidelines suggest that setting a blood pressure goal of 130/80 mmHg is appropriate. Given his age, one should be cautious about lowering his blood pressure too aggressively, leading to orthostasis and a subsequent fall. The older JNC8 guidelines had suggested a blood pressure goal of 150/90 mmHg for adults over age 60, but more recent evidence from the SPRINT trial argues that a lower goal in high risk patients (such as Mr. Wright, who has had a stroke already) decreases cardiovascular outcomes, particularly stroke.

Question 27

Diet

Answer 27

The ACC/AHA Lifestyle Guidelines recommend all adults consume a Mediterranean diet to reduce their risk of ASCVD. Furthermore, patients with hypertension should limit sodium intake to 2,400 mg per day or less.

Question 28

Physical activity

Answer 28

On the basis of moderate quality evidence, all adults are encouraged to engage in moderate-to-vigorous intensity physical activity 3-4 times per week for 40 minutes per session. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended.

Question 29

Stroke education

Answer 29

Stroke education including knowledge of stroke warning signs and need to call 911 in the event of a cerebrovascular event as well as awareness of individual's own risk factors.

Question 30

Recommended Tests for the Initial Emergency Evaluation of a Patient with Suspected Acute Ischemic Stroke

Answer 30

CT and MRI Imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke. Multimodal CT and MRI may provide additional information that will improve diagnosis of ischemic stroke. Class I, Level of Evidence A Renal function / electrolytes Abnormalities of renal function or electrolyte disturbances are prevalent in patients who have risk factors for stroke and should be assessed. Class I, Level of Evidence B Electrocardiogram (ECG) An electrocardiogram (ECG) is recommended because of the high incidence of heart disease in patients with stroke. General agreement supports the use of cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. It is generally agreed that cardiac monitoring should be performed during the first 24 hours after onset of ischemic stroke. Class I, Level of Evidence B Markers for cardiac ischemia Markers for cardiac ischemia are important for all patients with suspected ischemic stroke, as myocardial ischemia is a potential complication of acute cerebrovascular disease. CBC and PT/PTT Abnormalities of the CBC and PT/PTT provide information that should prompt consideration of infectious, hypoxic/hypoperfusion, thrombotic and hemorrhagic etiologies. Oxygen saturation Stroke etiology maybe due to underlying CAD and the extent of brain injury may be lessened by maintaining normal oxygen saturation . Hypoxic patients with stroke should receive supplemental oxygen.

Question 31

Cardiac Biomarkers

Answer 31

Troponins and other substances are released into the blood by ischemic or infarcting myocytes. B-type Natriuretic Peptide (BNP) is 32-amino-acid polypeptide secreted by the cardiac ventricles in response to ventricular volume expansion and pressure overload. The levels of BNP are elevated in patients with left ventricular dysfunction, and the levels correlate with both the severity of symptoms and the prognosis.

Question 32

Emergency CT Scanning and Decision to Treat with rtPA

Answer 32

Emergency CT scanning is done to identify most cases of intracranial hemorrhage and help discriminate nonvascular causes of neurological symptoms, like a brain tumor. The CT scan can also be examined for evidence of early signs of infarction, as widespread signs of early infarction are correlated with a higher risk of hemorrhagic transformation after treatment with thrombolytic agents. But, even so, data is insufficient that any specific CT finding (with the exception of hemorrhage) should preclude treatment with rtPA within three hours of stroke onset.

Question 33

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, most likely diagnoses: Sz

Answer 33

Seizure may present with an aura of dizziness or lightheadedness. May occur with sudden and extreme elevations of blood pressure associated with papilledema. May be followed by a brief period of temporary paralysis (Todd's paralysis). The seizure is followed by partial or complete paralysis on one side of the body and may also affect speech and vision. The average duration of the paralysis is 15 hours, but can last from thirty minutes to 36 hours at which point symptoms resolve completely. Aura is a disturbance of visual, hearing, taste, smell or altered body sensation usually arising for the temporal lobe signaling impending seizure onset. Amnesia for the event and alteration of consciousness is a hallmark of seizure disorder. A seizure (idiopathic or due to an identified cause) is unlikely if the patient has recall of the event, no post-ictal period of confusion, and no evidence of focal findings, oral injury, or urinary/fecal soiling.

Question 34

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, most likely diagnoses: Stroke

Answer 34

Dizziness and lightheadedness secondary to brain ischemia are common during stroke (also called cerebrovascular accident). Uncontrolled hypertension is a major stroke risk factor. A focal neurologic deficit (such as arm paresthesia) is a cardinal feature of stroke. Visual disturbance is a common stroke feature if the stroke occludes a retinal artery, produces ischemia in a visual cortex, or affects the right brain hemisphere, which governs visual spatial orientation. Consciousness may not be impaired, or a stroke patient may rapidly progress to coma and death depending on stoke type and infarct location and size. An irregular pulse is associated with an increased risk for embolic stroke and TIA. Common deficits that should alert medical professionals and the general public to the possibility of stroke include: sudden unilateral numbness or weakness of face, arm, or leg; sudden confusion, dysarthria; sudden visual disturbance; sudden gait disturbance, dizziness, loss of balance or coordination; and sudden severe headache with no known cause.

Question 35

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, most likely diagnoses: TIA

Answer 35

Dizziness and lightheadedness secondary to brain ischemia are common during transient ischemic attack (TIA). The area of brain function affected by a TIA is by definition limited and typically not severe enough to impair consciousness. TIA is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.

Question 36

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, most likely diagnoses: Coronary Artery Dz

Answer 36

Atrial fibrillation is associated with a significant risk of embolic stroke and coronary artery disease. New onset atrial fibrillation induced by acute myocardial ischemia would augment a transient drop in cardiac output caused by ischemic myocardium. Decreased cardiac output with brain hypoperfusion could manifest as lightheadedness, variable impairment of consciousness, sensori-motor dysfunction, irreversible brain injury, and even sudden cardiac death. Irregular heart rate is a sign of cardiac dysrhythmia.

Question 37

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, most likely diagnoses: Medication SE

Answer 37

Medication side effect should always be considered. Thiazide diuretics can produce electrolyte disturbances, which may then trigger arrhythmia. Hypokalemia is a common side effect of thiazide diuretics and can, if severe, result in cardiac arrhythmia, paresthesias, and muscle weakness. Estrogens and neuroleptics are both associated with increased stroke risk, although this patient takes neither. The side effect profile of antihypertensives includes lightheadedness and dizziness. Syncope can occur with initiation of alpha-blockers.

Question 38

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, less likely diagnosis: Brain Tumor

Answer 38

Dizziness and lightheadedness are not common presentations of brain tumor, although symptoms vary depending on tumor size and location. 25% of patients with a brain tumor report weakness or numbness in the arms or legs and 25% report visual problems. Behavioral and cognitive changes are common and often occur with impairment of memory, decreased concentration, and/or personality changes. Except in the case of acute hemorrhage, impairment of consciousness is a late finding.

Question 39

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, less likely diagnosis: Hypoglycemia

Answer 39

Severe hypoglycemia may present with sweating, altered consciousness, loss of coordination, parasthesias and focal neurologic findings. Therapy is prompt administration of IV glucose without which the patient may suffer irreversible neurologic damage.

Question 40

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, less likely diagnosis: Temporal arteritis

Answer 40

Patients with temporal arteritis may present with amaurosis fugax (transient monocular loss of vision) and cranial bruits. The incidence peaks in the early seventies with women representing 80% of the affected. Patients may present with symptoms including headache, malaise, scalp tenderness over the temporal artery, intermittent jaw claudication, and low-grade fever.

Question 41

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, less likely diagnosis: hypokalemic periodic paralysis

Answer 41

Hypokalemic periodic paralysis is a rare syndrome characterized by episodes of general or focal weakness. Episodes usually begin in childhood or adolescence. Paralysis most often occurs during the rest period following vigorous physical activity.

Question 42

Differential Dizziness / Lightheadedness With Focal Neurologic Findings, less likely diagnosis: hemiplegic migraine

Answer 42

Hemiplegic migraine is a rare form of migraine that can present as headache associated with hemiparesis with sensory deficits and motor weakness. This presentation of migraine is most common during childhood and adolescence with the cessation of symptoms by mid-adult life.