Download 1. Hemiplegia

The first problem. HEMIPLEGIA
*
in
common
older P4
ours
w
" ""
Spontaneous
"
"
""
Ima
concomitantornotion
"
"
Stroke ( ✗ 3}
•
*
contra in
^
,
/
Indications
indication :
↳
↳
•
traumatic
.
hemorrhages
"
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*
*
] (↳ ,
vs
Vision deficit ,
*
through ff
>
*
Initial part : step 1/2
extrapyramidal
Go
*
ischemic stroke within
limits
no
↳ T
V5
↳
4.5
hrs
age
contraindication :
risk of internal
bleeding
uncontrolled arterial
dicah
}
.
*
after
HT
(
>
esp
is
.
-4
procedure
!
i.
vascular
problems
g.
=
☐
m
!
Circulations
*
thrombolysis
mechanical
hemorrhage
intracranial
traumatic brain
post
"
↳
-
common
complication
acute
if
of cerebral vessels ( upto 6hrs0,
blockageof
blockage
( no
A. basilar is
< 4.5
defined time limit )
hrs IV
lhrombolysis therapy)
Anamnesis:
Anamnesis was obtained with the help of his wife because the patient cannot talk, he is able
to pronounce just few sounds although can understand what others are saying. Three months ago,
after a night sleep the patient experienced numbness of the right arm, however, the symptoms
resolved in about half an hour. The patient assumed that his arm became numb because he might
have overlain it while sleeping.. A few days ago while watching TV the patients lost his vision in
to
his left eye. A few minutes later his vision recovered and the patient did not seek for a medical
due
compressi
on (TIA) consultation. This morning after night sleep his wife has noticed that her husband could not talk, his
• In
mouth was deviated to the left, he could not move his right arm, could not sit down or stand up by
transitory
himself. She immediately called for the emergency.
I
.
Anamnesis vitae:
Arterial hypertension has been diagnosed 10 years ago, and the patient received a 5mg daily.
He had no traumas or operations, no allergies.
Habits:
Since the age of 20 years of age, the patient smokes one package of cigarettes and
drinks one glass of wine daily. He d e
e e ci e, alk
l a li le. Lately, the patient has been
concerned about his job because his employer bank undergoes reorganization and re-certification of
the employees.
Clinical examination:
General condition is normal. The patient is overweighted. Body temperature is
Atherosclerotic stenosis
normal.
Lymphatic
nodes and thyroid gland are of normal size. Cardiac tones are rhythmical, pulse
Uncontrolled HT
80 per minute. BP 190/110 mmHg. Peripheral arterial pulse can be palpated. Murmur in the regiono
Dyslipidemia
Paroxysmal arytnmia of the left carotid artery can be auscultated. Auscultation of the heart and lungs does not reveal any
changes. Examination of other systems does not show any deviations.
Risk factors
*
*
*
*
I
Neurological examination:
The a ie i i f ll c ci
e , ell ie ed. He d e
alk b i able c m ehe d
①
!
and
can
perform
given
tasks.
The
right
nasolabial
fold
is
shallow
(less
expressed), the right angle of
stag
the lip is deviated. Full right side hemiplegia with increased muscle tone and increased strech
reflexes is present. Abdominal reflexes are absent on the right. Positive Babinski sign on the right.
←
I?)
No sensory disturbances have been detected.
How you would define speech/language disturbance?
symptoms
? How you would define the paralysis of the lower part of the face and the right extremities?
presented
Which functions of the nervous system are damaged?
w/
suspicion
young patient
(
Transient ischemic attacks (
episodes)
Where is the lesion localized? UMN lesion ( contralateral)
)
ER
though
What is the possible etiology?
Acute vascular disorder/ stroke ( 3rd episode )
artery)
ER
What differential diagnosis should be made? Tumor
ischemic
Which additional diagnostics tests should be performed? CT w/o contrast
hemorrhagic?
Motor aphasia w/
CT
?
acute
How
big
is
the
urgency
of
ths
event?
ABC
thrombosis
protocol
angiography
lesion in Broka 's
any
ECG
left What treatment should be started?
glucose
( cortex ) lesion
Liver/ renal function
hemisphere Rehab control Aspirin heparin IV ( prophylaxis of statins
lesion
TBP
)
electrolytes
lung
shallow Students should request for additional anamnestic data and supplementary tests (prepared
facial CN
nasolabial
stable condition
Vision Deficit
Transcranial doppler
separately)
if >
70%
stenosis
*
Ask time the
first
*
>
acute
or
chronic
If
of vasculitis
,
not
MR2
in
[
•
I -2
*
*
vasculitis
metastasis Ms
( cerebral
,
,
,
~
or
>
•
"
"
•
>
.
↳
in
-
↳
•
,
,
'
in
thrombosis
•
02
•
↳
→
fold
•
Hemiplegia w/
CNS
•
L
.
eye
•
↳
[analyse
sign
( UMN
paralysis
loss of vision (
Babinsky
(the
temporary
arteries
)
]
T
non
-
department {
Neurology
specific;
deep tendon reflex )
*
*
Neck US (
carotid arteries)
*
Cholesterol
+
lipids
levels
✓
*
*
warning sign
suspect
of
"
amaurosis
a
stroke
fugax
due ↳ blood clot
dislodged
reduced
> m
.
cerebral arteries
(
commonly
plaque
blood
/
}
flow
due to carotid
artery blockage )
bleeding )
>
redo CT24 hrs later
'
lhrombolectomy
,
additionally
injury
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Emergency room
Mr J.J., 60 year-old bank officer was admitted to the emergency room due to development
of weakness in the right limbs and inability to talk.
*
intracerebral
,oommµg
start
•
giant
therapy
Pathways by which
Pyramidal
motor
signals
are
sent from brain
>
LMN
>
innervates
mm
produce
*
*
Originates
Carries motor
in
Responsible
movement
Extrapyramidal
tracts
✓
*
to
tracts
✓
cerebral cortex
fibres to
for
spinal
voluntary control
*
cord
3 brainstem
of the musculature of the
body
3 face
Originates
in
the brainstem
*
Carries motor fibres to
*
Responsible
control
for
involuntary
muscle tone
↳ balance
^
^
spinal
↳
posture
↳
locomotion
cord
3 autonomic
of all musculature , such
↳
I
the
as
:
*
Middle cerebral
*
Embolism from I. carotid
stenosis
artery
>
a.
supplies
ophthalmic
face
>
disturbed
i
reverse
a.
flow of
blood
*
*
*
stenosis
Cortiaobulbar tract
cerebral trauma
Lower
Left
frontal
,
damage
→
hemisphere
>
facial
dysarthria
→
speech impairment
i
cortical
1-
UMN
"
*
*
/ frontal
lesion
Alternating syndrome
"
when lesion
→
in
Arch of reflex
central
>
specific
Thrombolysisz
↳
w/
6
hrs
>
carotid
12
his
>
vestibular basilar
ischemic stroke
I 30%
paralysis
treatment
✓
acute
( ventral part )
brainstem
damage
*
pathology
region
ischemic
stroke
>
transient
vision
loss
ganglia
*
Basal
*
Brainstem
*
Cerebellum
( pons )
✗
Step 2/2
The further course of the disease:
The patient is slowly getting better. Twelve days following the beginning of the disease he
still experiences difficulties in talking, there is slight asymmetry of the face because of the less
expressed nasolabial fold. The patient can move his right arm but cannot move his hand. Muscle
tone in the hand and arm is increased, spastic. Reflexes on the right upper extremity are brisk, with
outspread reflexogenic zones. Muscle strength in the legs allows standing. Muscle tone of the right
leg is increased, patellar and Achille tendon reflexes are exagerated, ancle clonus and Babinski sign
are present. The patient walks with extended leg and holds his right arm in flexed position.
R¥
Wernicke 's
<
position
What further management is needed for this patient?
Aspirin
3-4 months
§☐fo× for flexion ( functionality T )
( pain )
periodically
General content of the problem:
Clinical problem
Speech disturbance and right-sided paralysis in the patient who
experienced transitory blindness and numbness of the right arm
and who is smoking, has increased BP and limited physical
activity.
Diagnosis
Ishaemic stroke in the region of the left a. carotis
Nosologic entity
Stroke
Risk factors of cardiovascular diseases
Most important aspects
Anamnesis with evaluation of all circumstances, clinical and
neurological examination. Differential diagnosis
Search for etiology
Treatment of the acute stage and secondary prophylaxis
Prophylaxis of complications
Rehabilitation
Setting
Emergency room
Department of Neurology
Learning objectives:
Upon accomplishment of this problem, the students are expected to know the following:
Diagnose stroke on the basis of anamnestic data and clinical evaluation;
Recognize the importance of transitory ischaemic attack as a risk factor for development of
stroke;
Diagnose the different types of acute stroke and be able to make differential diagnosis;
Be aware of the complementary tests that should be performed and be able to interpret them;
Know the main etiology of stroke;
Know the main risk factors for the development of stroke.;
Know the principles of the treatment in acute stage and secondary prophylaxis;
Understand the importance of rehabilitation and socio-economic consequences of disability.
<
>
Subject - Neurology
Responsible Department – Neurology
Literature:
Basic:
1. Mattle H, Mumenthaler M. Fundamentals of Neurology: An Illustrated Guide. 2nd ed.
Chapters 1-5, 12.
2. Simon RP, Aminoff MJ, Greenberg DA. Clinical Neurology, 10th edition.: McGraw-Hill,
New York, 2018.
3. Lectures in clinical neurology.
Supplementary:
4. Duus P. Topical Diagnosis in Neurology. New York, 2012.
5. www.emedicine.com