Home Head and Neck Cerebro Vascular Accident
Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

63 year old male patient presented with

Slurring of speech since 1 day associated with deviation of angle of mouth to the left side.

No history of weakness of limbs, loss of consciousness, seizures, fever, altered sensorium.

Patient was newly detected to be hypertensive.

No h/o diabetes mellitus.

No history of Smoking.
History of consumption of Alcohol since 10-15 years

A 63 year old male patient moderately built and nourished, well oriented to time place and person.

No pallor, icterus,
clubbing, cyanosis, lymphadenopathy, edema.

VITALS-
PR:64b/m
BP:220/110mmHg
RR:16 cycles/min
SpO2:97% on room air.

SYSTEMIC-
CVS-S1 S2 heard, no murmurs.
RS-Bilateral NVBS
PA-Soft, non-tender
CNS-Conscious, higher functions intact.
Patient had UMN facial Palsy in the form of
Deviation of the angle of the mouth towards the left side.
Patient able to close the eyes properly and wrinkling of the forehead present bilaterally
Dysarthria present.

Other cranial nerves normal.
Motor-
Deep tendon reflexes- normal
Plantar- B/L flexor
UL- Left side power-5/5, right side-Weakness of the distal muscles of the small muscles of the hand
LL- left side-5/5, right side-5/5
Sensory- normal
Cerebellum-normal
Gait- Normal

BLOOD : Hb– 16.1gm/dl
Tlc – 9350cells/cumm
Rbc count – 4.64million/cumm
Platelet count – 2lakh/cumm
Reticulocyte count – 2.6%
MCV – 98.1fl, MCH – 34.7pg
MCHC-35.4gm/dl
Peripheral Blood Smear: Normocytic normochromic blood picture.
RBS-121mg/dl
Uric acid-5mg/dl
LFT- Normal
Carotid Doppler-
-Diffuse atherosclerotic disease of bilateral carotid vessel system.
-Mixed plaque in right carotid bulb causing no significant luminal narrowing/ haemodynamic changes.
Fundoscopy normal.
ECHO-
-Concentric left ventricular hypertrophy
-No regional wall motion abnormality, clots, vegetation, pericardial effusion.
-normal left ventricular systolic function, EF- 64%
-Grade I L.V Diastolic dysfunction.
MRI Brain Report-
-acute infarcts in left corona radiata and capsuloganglionic region.
-age related cerebral atrophy with few chronic small vessel ischaemic changes.

Newly detected Hypertension with Facio-brachial monoparesis on Right side

Tab Atorvastatin 40mg P/O Stat and HS
Tab Asprin 75mg P/O HS
Tab Clopidogrel 75mg HS
Tab Cilnidipine 10mg 1 BD
Inj. Citicoline 500mg IV
Inj. Thiamine 500mg IV Q8H

Speech therapy in view of dysarthria.

Cerebrovascular accident or stroke is when blood flow to a part of brain is stopped either by a blockage or the rupture of blood vessels. It is of two types- an ischemic stroke caused by a blockage, a haemorrhagic stroke caused by the rupture of a blood vessel.(1) Both types of stroke deprive part of the brain of blood and oxygen.
Ischemic stroke is the most common.
Symptoms of cerebrovascular accident varies depending on the site of the lesion.(2)
-dysarthria,
-facial muscle weakness or numbness
-paralysis of of one side of the body or weak muscles
-dizziness
-blurred vision
-loss of balance and coordination
-difficulty in walking
-rapid involuntary eye movement
Investigation; CT or MRI of the brain
Treatment of cva-
Drugs like –
If the patient comes in the golden hour( within 3 hours), thrombolytic like Tissue Plasminogen activator like Alteplase is given. Before using it CT brain to be done to rule out Haemorrhage.
Other medications like antiplatelets, statins(plaque stabilizer),are given. antihypertensive drugs if required is given.
Speech therapy, occupational therapy, physiotherapyare provided depending on the deformity.
Faciobrachial monoparesis is presumed to be secondary to lesions involving Heubner artery (a proximal perforating branch from anterior cerebral artery) or lateral lenticulostriate artery(branch of middle cerebral artery) Occlusion of these perforating branches causes small vessel stroke.Hypertension and age are principal risk factors of these small artery strokes.(3)

  1. Andrade SE, Harrold LR, Tjia J, Cutrona SL, Saczynski JS, Dodd KS, Goldberg RJ, Gurwitz JH. A systematic review of validated methods for identifying cerebrovascular accident or transient ischemic attack using administrative data. Pharmacoepidemiology and drug safety. 2012 Jan;21:100-28.
  2. ACLS Suspected Stroke Algorithm [Internet]. [cited 2019 Oct 17]. Available from: https://www.acls.net/acls-suspected-stroke-algorithm.htm
  3. Jain SH, Prashanth S, Bhat SS, Jayaraj SG. Faciobrachial Monoparesis secondary to borderzone Infarct : A Case Report. J Pub Health Med Res, 2013;1(2):108-09

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