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4th TIME CRITICAL DIAGNOSIS SUMMIT

Naresh Mullaguri MDNeurology Resident physician

University of MissouriColumbia, Missouri

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What to do next?

Disclosures : None

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Case54-year old right handed Caucasian femaleLKW – 1550 PM. Symptom onset – 1555 PMSymptoms: sudden onset right sided weakness and unable to speak. Also had confusion and agitation. Witnessed by her daughter and called EMS. She had h/o loose stools for the past 3 days.PMHx: TIA 10 years ago with similar symptoms of right sided weakness and inability to speak. Patient not on any antiplatelet or anticoagulants at home.She was taken to OSH by EMS at 1635 pm.

Time elapsed – 45min

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What is the next appropriate step?

Send her to CT scan of the HeadFinger stick Blood GlucosePerform NIH stroke scaleWait for more history from daughter

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What is the next appropriate step?

Send her to CT scan of the HeadFinger stick Blood GlucosePerform NIH stroke scaleWait for more history from daughter

NIHSS - 25

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Finger-stick Glucose of 87mg/dlShe was taken to the CT scanner – No hemorrhage.

What do you do next?a) Do a CT perfusion scanb) Mix the t-PAc) Assess the inclusion and exclusion criteria for t-PAd) Wait for the daughter to obtain consent for t-PA

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What do you do next?a) Do a CT perfusion scanb) Mix the t-PAc) Assess the inclusion and exclusion

criteria for t-PAd) Wait for the daughter to come to

get consent for t-PA

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The ER physician noticed some jerking movements on the left side of the body on her way back from CT scanner. Diagnosed as Stroke with possible seizure*. 1mg of Ativan was given and also loaded with 1gm Keppra. INR – 1.0Decided to transfer the patient to the University hospital as he is not a t-PA candidate.

*Seizure at stroke onset is a relative contraindication for t-PA

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She arrived to UH ER via ambulance at 1905 pm.

Time elapsed – 3hr 10min

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What do you do next?a) seizure with post ictal weakness, no acute

intervention.b) Calculate NIH stroke scale.c) Do a CT and CT Angiogram of the Head and Neck.d) Admit the patient to the Neurology service.

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What do you do next?a) seizure with post ictal weakness, no acute

intervention.b) Calculate NIH stroke scale.c) Do a CT and CT Angiogram of the Head and Neck.d) Admit the patient to the Neurology service.

NIH Stroke scale - 18

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CT Angiogram of the Head and Neck was performed which showed Left sided proximal MCA occlusion.

What would you do next?a) Call Interventionist for mechanical

thrombectomy.b) Start t-PA immediately as she is within

extended window.c) Order CT perfusion of the Head to assess

penumbra.d) Call the daughter to explain the situation.

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What would you do next?a) Call interventionist for mechanical thrombectomy.b) Start t-PA immediately as she is within extended

window*.c) Order CT perfusion of the Head to assess

penumbra.d) Call the daughter to explain the situation.*There is no specific history of Seizure and even if there is a focal seizure with Stroke, it is a relative contraindication and her symptoms do not correlate with seizure but with occluded left MCA, which is her dominant hemisphere and might leave her with significant disability if left untreated.

T-PA started at 1930 PM after obtaining verbal consent from husband.

Time elapsed – 3hr 35min

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What do you do next?a) Call the interventionist for mechanical

thrombectomyb) Wait for the t-PA to finish and reassess her

symptomsc) Admit the patient to neurosciences intensive care

unit for further care.d) Call and appreciate outside ER physician for his

timely help.

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What do you do next?a) Call the interventionist for mechanical

thrombectomy*.b) Wait for the t-PA to finish and reassess her

symptoms.c) Admit the patient to neurosciences intensive care

unit for further care.d) Call and appreciate outside ER physician for his

timely help.*Left M1 occlusion – within 6hr time window for endovascular intervention.

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She had a successful mechanical thrombectomy. She was transferred to the NSICU – she improved significantly with NIH of 0 at discharge. She was monitored for A.fib at discharge with a loop recorder. She was prescribed Aspirin, Plavix and a statin.Modified Rankin Score at 90days is “0”

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Thank you

Acknowledgements: Brandi French MD, Arun Kumar MD, Tami Harris SCRN