Makindo Medical Notes

Mary is an 80-year-old lady who developed some altered speech whilst out on a day trip shopping from Chelmsford to Brighton. She was found to have right face, arm and leg weakness and has difficulty with speech and language. She has been brought in by paramedics. She complains of a headache. The time of onset was 5.20 pm. She was FAST positive for speech and arm weakness.
Her ECG shows AF. The paramedics think she is worse than when they picked her up. She has diabetes and her BM is 8.9. She has a long history of hypertension and the BP is 200/70 mmHg. She has an NIHSS of 15. It is now 6 pm. You attend the stroke call with the specialist nurse. She has no local hospital records as she is away from home.

1. Do you think this will be an ischaemic or haemorrhagic stroke

The clues for haemorrhage would be the gradual clinical deterioration as bleeding is a dynamic process and can gradually worsen, the history of hypertension and headache. Ischaemic strokes tend to be at their maximum within the first few minutes of onset but there are sometimes exceptions where the onset is more gradual. The AF suggests she might have had a cardioembolic ischaemic stroke. Ischaemic stroke is generally commoner in this population. Patients in AF may also be on anticoagulants. The only sure way to tell is...

2. What is the most important test

See Answer

A non-contrast CT head scan is the quickest way to reliably tell if a stroke is ischaemic or haemorrhagic. CT is very sensitive for blood.

3. Click to see the CT scan

See Answer

4.Intepret the Scan

See Answer

The CT below shows a left subcortical haemorrhage. There is minimal oedema and just a tiny amount of midline shift. Haemorrhagic strokes cause 15% of all strokes. It would be good practice to repeat the CT if things got any worse if the patient was someone who might benefit from neurosurgery. It is customary to refer to neurosurgeons though uncomplicated bleeds like this are usually managed conservatively.

5. What actions should you consider

See Answer

ABC and admission to HASU. Consider ITU if GCS < 9. Check clotting and platelets. The AF concerns us that the patient may be on Warfarin and a raised INR would suggest this. Try and check the patient's medications as they may also be on a DOAC. These would need their specific reversal agent. Stop any Clopidogrel or Aspirin. Monitor and Lowering BP cautiously using local protocols. Monitoring BMs as diabetic. Swallow assessment. Contacting family or those important to the patient to let them know the situation but also to get as much background history as possible and baseline functional status and any views expressed on resuscitation.

6. What are the commonest causes of ICH in this age group

See Answer

• Chronic hypertension
• Cerebral amyloid angiopathy
• Anticoagulants e.g. on warfarin
• Trauma
• Bleeding associated with a tumour
• Arteriovenous Malformation or Cavernoma

7. The INR is 2.2. What actions should you consider

See Answer

A bedside INR tests shows the INR is 2.2. This would suggest the patient is on Warfarin. The most effective way to reverse the Warfarin is to give Vitamin K 10mg IV and 4 factor Prothrombin complex concentrate such as Beriplex or Octaplex. This usually comes from the blood bank and you will need to call them and explain the urgency. It is very expensive and in some centres you may need to discuss with haematology consultant on call. In some centres it can be ordered by the stroke consultant and this helps to speed up the process. Ensure this is prescribed and administered as soon as possible. Usually in a life-threatening bleed the full dose (50 u/kg) is given. You will need to know body weight.

References

---

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

Edit