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WEEKLY STROKE REVIEW

WEEKLY STROKE REVIEW. 12–3 THRU 12–9–17 Presented by Dr. Flaster. Care Timeline MRN: 0590347 Total (NIH Stroke Scale): 2 12/3/2017 Adams, William H, MD 1721  Arrived 1723  Urinalysis POCT 1731  ISTAT Troponin 1733  ISTAT Creatinine ISTAT GFR 1735  ISTAT TROPONIN (LABEL ONLY)

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WEEKLY STROKE REVIEW

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  1. WEEKLY STROKE REVIEW 12–3 THRU 12–9–17 Presented by Dr. Flaster

  2. Care Timeline MRN: 0590347 Total (NIH Stroke Scale): 2 12/3/2017 Adams, William H, MD 1721  Arrived 1723  Urinalysis POCT 1731  ISTAT Troponin 1733  ISTAT Creatinine ISTAT GFR 1735  ISTAT TROPONIN (LABEL ONLY) Comprehensive Metabolic Panel (CMP) ISTAT Creatinine CBC with Differential Protime w/INR and PTT Extra Green Lithium Tube Hold Blood Bank Specimen 1745  Iohexol 80 mL 1751  CT HEAD STROKE ALERT 1756  Point of Care Glucose 1757  XR CHEST AP PORTABLE STROKE ALERT 12 Lead EKG - Testing for ED 1800  CT ANGIOGRAM HEAD 1801  CT ANGIOGRAM NECK 1932  Microscopic POC 2209  MR BRAIN WO CONTRAST MR ANGIOGRAM HEAD WO CONTRAST 2210  MR ANGIOGRAM NECK WO CONTRAST 2243  Admitted This is a 74-year-old gentleman who had slurred speech and weak legs. He was a prehospital stroke alert but seems to have improved in route. Patient was seen by Dr. Adams who found no focal deficits. He still may have had mildly slurred speech. He was seen shortly thereafter by Dr. Martin who reported right leg weakness and numbness at onset. He also may have had some word finding difficulty. The patient was taking clopidogrel and aspirin and had undergone transcutaneous aortic valve replacement 5 weeks earlier. On exam he had dysarthria, slight tremulousness of the right arm and subjective sensory complaints involving the right leg. CT head showed diffuse cerebral atrophy. CT angiography showed diffuse atherosclerotic change but no large vessel occlusion. It was concluded that the patient was neither a thrombolytic or mechanical thrombectomy candidate. He was admitted to medicine for observation and an MRI of the brain was obtained which demonstrated a single small diffusion restriction in insular cortex on the left. MR angiography of the head and neck were obtained unnecessarily. The patient improved but required rehabilitation after discharge on the third hospital day. He was discharged on the dual antiplatelet therapy he came in with and also statin.

  3. ESUS however very late minor procedural embolism perhaps a possibility.

  4. Care Timeline MRN: 0174096 Total (NIH Stroke Scale): 18 12/03 Lintz, Scott A, DO 2031  Arrived 2035  Ondansetron HCl No dose recorded Etomidate 20 mg 2036  Succinylcholine Chloride 120 mg 2043  ISTAT TROPONIN (LABEL ONLY) CBC Comprehensive Metabolic Panel (CMP) Prothrombin Time w/INR ISTAT Creatinine 2044  Midazolam HCl 5 mg 2046  ISTAT Troponin Propofol 30 mcg/kg/min 2048  ISTAT Creatinine ISTAT GFR 2051  Propofol 50 mg 2100  Iohexol 60 mL 2106  CT HEAD STROKE ALERT 2114  XR CHEST AP PORTABLE STROKE ALERT 2122  12 Lead EKG - Testing for ED 2123  CT ANGIOGRAM HEAD CT ANGIOGRAM NECK 2128  Arterial Blood Gas 2132  alteplase (ACTIVASE) 8.4 mg in SWFI 8.4 mL IV... 8.4 mg 2133  Point of Care Glucose 2134  alteplase (ACTIVASE) 75.7 mg in SWFI 75.7 mL... 75.7 mg 2203  BC - Routine Single Order Lactate (Lactic Acid), Blood Procalcitonin 2205  BC - Routine Single Order 2226  Admitted 12/04 0155  MR BRAIN WO CONTRAST 12/05 1147  ECHOCARDIOGRAM This is a 50-year-old gentleman who was having dinner when he suddenly "collapsed". EMS found the patient with left hemiparesis and a right gaze preference. He was a prehospital stroke alert. Dr. Lintz saw the patient immediately. He was nonverbal. He vomited. He was intubated emergently. He was seen very shortly thereafter by Dr. Martin.

  5. CT head was unremarkable. CT angiography of the head and neck were unremarkable. A large vessel occlusion was not present. Dr. Martin felt it would be reasonable to treat the patient with IV tPA given the focal features on examination prior to intubation. Patient was extubated on the second hospital day with an improving neurologic examination. He was discharged to rehabilitation on the fourth hospital day. This appears to be an embolic stroke of unknown source. Echocardiogram was normal. A PFO with a left-to-right shunt is reported. Patient was discharged on aspirin and statin. Was there a seizure at stroke onset? Cardiac event monitoring is needed. Urine tox screen was not sent.

  6. Care Timeline MRN: 9032598 Total (NIH Stroke Scale): 19 12/4/2017 Medina, Timothy J, MD 1404  Arrived 1410  ISTAT TROPONIN (LABEL ONLY) ISTAT Creatinine Urinalysis POCT 1414  Extra Green Lithium Tube 1416  Comprehensive Metabolic Panel (CMP) CBC with Differential Protime w/INR and PTT Hold Blood Bank Specimen 1417  ISTAT Troponin 1418  ISTAT Creatinine ISTAT GFR 1429  Iohexol 60 mL 1434  CT HEAD STROKE ALERT 1441  XR CHEST AP PORTABLE STROKE ALERT 1444  CT ANGIOGRAM HEAD CT ANGIOGRAM NECK 1448  Point of Care Glucose 1541  12 Lead EKG - Testing for ED 1606  LORazepam 1 mg 1716  Toxic Screen, Urine, No Confirmation 1724  Urine Culture Microscopic POC 1912  Discharged This is a 32-year-old woman who was in class at a community college when she became lightheaded. She reportedly nearly fainted twice. Fire rescue was called. In route to the hospital she became unresponsive but awake. She was said to be tearful. Dr. Medina evaluated her at triage and initiated a stroke alert. She was seen shortly thereafter by Jennifer Yoder CRNP and Dr. Salama. CT head was unremarkable CT angiography of the head and neck were unremarkable. The patient was awake and alert, would occasionally nod her head to questions. She seemed to move 4 extremities well at times. A family member explained that the patient was under a great deal of stress. She received an Ativan injection and thereafter became cooperative without a focal neurologic examination. She was discharged from the ED.

  7. This is a 64-year-old man who developed slurred speech, "felt weird" and then left upper extremity weakness. He was a prehospital stroke alert. He was evaluated by Dr. Davies and then very shortly thereafter by Jennifer Yoder CRNP and Dr. Salama. On examination he was found to have mild left hemiparesis and dysarthria and some mild left sensory loss. His CT head was unremarkable. CT angiography of the head and neck were also unremarkable. There was no large vessel occlusion. IV TPA was administered at 36 minutes door to needle time. Subsequently MRI brain showed diffusion restriction in the right MCA territory, mostly involving a distal branch vessel in the superior division just posterior to the motor strip. There was some hemorrhagic transformation on MRI indicative of reperfusion. Patient improved clinically. Patient experienced a run of ventricular tachycardia which was asymptomatic during his hospitalization. Some atrial tachycardia was noted but not atrial fibrillation. A cardiac source is suspected but not proven in this man with hypertension, diabetes, morbid obesity and obstructive sleep apnea. Care Timeline MRN: 1192235 Total (NIH Stroke Scale): 11 12/05 Davies, Trystan H, MD 1205  Arrived 1213  Point of Care Glucose 1214  Extra Green Lithium Tube Extra Gold Top Tube 1215  ISTAT TROPONIN (LABEL ONLY) Comprehensive Metabolic Panel (CMP) ISTAT Creatinine CBC with Differential Protime w/INR and PTT ISTAT Troponin Hold Blood Bank Specimen 1217  ISTAT Creatinine ISTAT GFR 1227  XR CHEST AP PORTABLE STROKE ALERT 1228  CT ANGIOGRAM HEAD 1229  Iohexol 60 mL 1230  CT HEAD STROKE ALERT CT ANGIOGRAM NECK 1236  alteplase (ACTIVASE) 9 mg in SWFI 9 mL IV Syringe 9 mg 1238  alteplase (ACTIVASE) 81 mg in SWFI 81 mL infusion 81 mg 1239  12 Lead EKG - Testing for ED 1349  Admitted 12/06 1140  ECHOCARDIOGRAM 1945  MR BRAIN WO CONTRAST

  8. Care Timeline MRN: 2320838 NIH stroke scale is 2 12/5/2017 Davies, Trystan H, MD 1533  EKG - Ambulance 1534  EKG - Ambulance 1606  Arrived 1607  Urinalysis POCT 1614  ISTAT Troponin 1615  ISTAT TROPONIN (LABEL ONLY) Comprehensive Metabolic Panel (CMP) ISTAT Creatinine CBC with Differential Protime w/INR and PTT Extra Green Lithium Tube ISTAT Creatinine ISTAT GFR Hold Blood Bank Specimen 1629  XR CHEST AP PORTABLE STROKE ALERT 1632  CT HEAD STROKE ALERT CT ANGIOGRAM HEAD 1633  Iohexol 60 mL CT ANGIOGRAM NECK 1642  Point of Care Glucose 1644  12 Lead EKG - Testing for ED 1655  Aspirin 325 mg 1935  Admitted to Observation This is a 50-year-old woman who reported that she had headache and chest pain that radiated to her neck followed 2 hours later by numbness and tingling of the left upper and lower extremity. She was brought in by EMS. Dr. Davies evaluated her at triage and initiated a stroke alert. Dr. Salama evaluated her shortly thereafter. Initially he noted some left-sided paresthesias and mild left-sided weakness. This resolved over the next 15 minutes and he recorded NIH stroke scale of 0 when CT head was completed. CT head was unremarkable. CT angiography of the head and neck are unremarkable. Patient was considered to have had a TIA and aspirin was given. She was admitted to medicine for observation. MRI brain was then obtained which demonstrated neither acute or chronic ischemia. A component of the patient's problem may have been migraine. She does have a history of ocular migraine. She has hypertension and obesity additionally. Anxiety may play a role. Patient was discharged on low-dose aspirin and statin.

  9. This is a 39-year-old woman who initially was said to be normal when she awoke. She had right facial numbness and then developed his speech difficulties and right-sided weakness. She was prehospital stroke alert. She was seen by Dr. Scull and then very shortly thereafter by Dr. Salama and Jennifer Yoder CRNP. Neurology team was able to elicit from the patient that she awoke with the right facial symptoms. This would therefore be a wake-up stroke. CT head was unremarkable. CT angiography of the head and neck were similarly unremarkable. There is no evidence of atherosclerosis on my review. The patient improved but still had weakness and language difficulties. Dr. Salama concluded that the patient was neither of thrombolytic nor a thrombectomy candidate. Further, it turns out that she has a history of nonepileptic seizures. She is followed by the neurology group of Dr. M-Kumar. Her deficits persisted but MRI of the brain showed neither diffusion restriction nor signs of previous ischemia. The patient was discharged the following day with a diagnosis of psychogenic weakness and the possibility of complicated migraine. The patient was seen by Dr. Wu Chen in neurologic consultation who noted that the patient was not having seizures. Review of prior records shows that the patient had left-sided weakness and slurred speech in April 2015 and had a normal MRI at that time as well. Care Timeline MRN: 0636350 Total (NIH Stroke Scale): 6 12/6/2017 Riley, Daron P, MD – Dr. Scull 1019  Arrived 1025  ISTAT TROPONIN (LABEL ONLY) CBC Comprehensive Metabolic Panel (CMP) Prothrombin Time w/INR ISTAT Creatinine Extra Green Lithium Tube ISTAT Troponin Hold Blood Bank Specimen 1026  ISTAT Creatinine ISTAT GFR 1032  Iohexol 60 mL 1034  CT HEAD STROKE ALERT 1038  XR CHEST AP PORTABLE STROKE ALERT 1041  CT ANGIOGRAM HEAD CT ANGIOGRAM NECK 1151  12 Lead EKG - Testing for ED 1421  Admitted to Observation

  10. This is an 89-year-old woman who was found by her daughter at home lying on the floor beside her bed. EMS reported right-sided facial droop and a left gaze preference. The patient was nonverbal and unable to follow commands. She was prehospital stroke alert. Dr. Davies saw her immediately. He noted marked right neglect, global aphasia and moderate right-sided weakness involving both the arm and leg. Dr. Salama recommended not considering thrombolytic therapy because of concern for "cerebral amyloid angiopathy". CT head does show old bilateral hemispheric strokes and cerebellar strokes as well. Dr. Davies discussed the case with the patient's family. It seems that they were planning to consult hospice the following morning in any event. They also did not feel thrombolytic would be appropriate. The patient was admitted to medicine with DO NOT RESUSCITATE status. Troponin was elevated at 13.59. The patient had been admitted for an acute MI a week earlier when it had been decided that only "medical therapy" would be appropriate from that point on. Echo at that time noted multiple wall hypokineseswith an EF of 30%. Aspirin was given. The patient remained aphasic and was discharged to an extended care facility with hospice following 5 days later. Care Timeline MRN: 0291007 NIH not done 11/29/2017 Scull, Stephen J, MD—Dr. Davies 1904  Arrived 1908  ISTAT TROPONIN (LABEL ONLY) ISTAT Creatinine 1911  Extra Green Lithium Tube 1913  Comprehensive Metabolic Panel (CMP) CBC with Differential Protime w/INR and PTT ISTAT Troponin Hold Blood Bank Specimen 1914  ISTAT Creatinine ISTAT GFR 1926  CT HEAD STROKE ALERT 1929  12 Lead EKG - Testing for ED 1930  XR CHEST AP PORTABLE STROKE ALERT 1956  Point of Care Glucose 2003  Aspirin 300 mg 2005  Sodium Chloride 1000 mL 2143  Admitted to Observation

  11. Possible dense vessel sign. Most of the encephalomalacia would seem to represent old infarcts. CAA should always be considered in this age group but is conjectural.

  12. Care Timeline MRN: 0068241 Total (NIH Stroke Scale): 4 12/6/2017 Hershberger, Leonard S, MD 2044  Arrived 2101  Point of Care Glucose 2104  ISTAT Troponin 2105  ISTAT Creatinine ISTAT GFR 2106  ISTAT TROPONIN (LABEL ONLY) Comprehensive Metabolic Panel (CMP) ISTAT Creatinine CBC with Differential Protime w/INR and PTT Extra Green Lithium Tube Hold Blood Bank Specimen 2116  Iohexol 60 mL 2122  EKG 12-Lead 2124  CT HEAD STROKE ALERT 2126  XR CHEST AP PORTABLE STROKE ALERT 2132  CT ANGIOGRAM HEAD CT ANGIOGRAM NECK 2142  Sodium Chloride 1000 mL 2143  Ketorolac Tromethamine 15 mg 2145  DiphenhydrAMINEHCl 25 mg 2146  ProchlorperazineEdisylate 10 mg 2356  Discharged This is a 47-year-old gentleman who came to the ED because of slurred speech, difficulties expressing himself and left-sided weakness which began 30 minutes prior to arrival. He indicated that he had a history of complicated migraines and TIA. Dr. Hershberger evaluated the patient in triage and initiated the stroke alert. Dr. Salama so the patient shortly thereafter. Dr. Salama found the patient with stuttering speech and no focal weakness. He felt this to be complicated migraine which would require no stroke therapy. Patient received Toradol and his symptoms resolved and he was discharged from the ED.

  13. Care Timeline MRN: 0029785 Total (NIH Stroke Scale): 3 12/7/2017 Medina, Timothy J, MD 1259  Arrived 1313  Extra Green Lithium Tube Hold Blood Bank Specimen 1314  ISTAT TROPONIN (LABEL ONLY) Comprehensive Metabolic Panel (CMP) ISTAT Creatinine CBC with Differential Protime w/INR and PTT Magnesium, Serum 1316  ISTAT Troponin 1318  ISTAT Creatinine ISTAT GFR 1324  XR CHEST AP PORTABLE STROKE ALERT 1325  CT HEAD STROKE ALERT 1327  12 Lead EKG - Testing for ED 1332  Point of Care Glucose 1358  Aspirin 324 mg 1507  Admitted to Observation This is an 85-year-old woman who came to the ED complaining of left facial pain and left facial numbness as well as a left facial droop. She also complained of dizziness. Dr. Medina came to evaluate the patient in triage and initiated stroke alert. Dr. Salama saw the patient. On examination he found no focal deficits although the patient continued to complain of paresthesias involving the lower face. He gave her an NIH stroke scale of 1 and did not consider her a tPA candidate. She was on warfarin for paroxysmal atrial fibrillation and her INR proved to be 2.8. CT head was unremarkable. The patient was admitted to observation under family medicine and discharged the following day.

  14. Care Timeline MRN: 1223605 Total (NIH Stroke Scale): 1 12/7/2017 Lintz, Scott A, DO 1643  Arrived 1710  ISTAT TROPONIN (LABEL ONLY) CBC Comprehensive Metabolic Panel (CMP) Prothrombin Time w/INR ISTAT Creatinine ISTAT Creatinine ISTAT GFR Extra Green Lithium Tube Hold Blood Bank Specimen 1715  CT HEAD STROKE ALERT 1721  XR CHEST AP PORTABLE STROKE ALERT 1725  12 Lead EKG - Testing for ED 1919  MR BRAIN WO CONTRAST 2029  Aspirin 324 mg 2047  Discharged This is a 39-year-old woman who came to the emergency Department complaining of left facial numbness. She had some vague dizziness. She had a mild headache. She described a few seconds of blurred vision. She was seen at triage by Dr. Lintz and a stroke alert was initiated. Dr. Lintz notes that the patient was evaluated by Dr. Salama who found no deficit other than subjective numbness. CT head was obtained and subsequently MRI brain. These studies were unremarkable, the patient felt better and was discharged from the ED. (Neurology note not on chart.)

  15. Care Timeline MRN: 2237948 Total (NIH Stroke Scale): 1 12/8/2017 Medina, James, MD 1217  Arrived 1240  ISTAT TROPONIN (LABEL ONLY) CBC Comprehensive Metabolic Panel (CMP) Prothrombin Time w/INR ISTAT Creatinine Extra Green Lithium Tube Hold Blood Bank Specimen 1249  ISTAT Troponin 1251  ISTAT Creatinine ISTAT GFR 1301  CT HEAD STROKE ALERT XR CHEST AP PORTABLE STROKE ALERT 1311  Iohexol 60 mL CT ANGIOGRAM HEAD CT ANGIOGRAM NECK 1410  EKG 12-Lead 1614  MR BRAIN WO CONTRAST 1653  Discharged This is a 74-year-old woman who developed left facial numbness as well as numbness of the left hand and toes prompting her to come to the emergency department she was seen at triage and then evaluated by Dr. Medina who initiated a stroke alert. She was then seen by Jennifer Yoder CRNP and Dr. Salama. NIH stroke scale was 0 at that point. CT head was unremarkable while CT angiography showed no large vessel occlusion and only mild right internal carotid artery origin atherosclerosis. Patient was felt not to be a thrombolytic candidate. Patient is a smoker with hyperlipidemia and has a history of migraine and reportedly TIA. MRI brain was obtained and this showed no acute ischemia or chronic ischemic changes. She was discharged from the ED on aspirin and statin.

  16. This is a 73-year-old gentleman with a history of hypertension and remote systemic lymphoma who experienced left sided distal upper extremity numbness and awkwardness, was seen at Parksburgurgent care and referred to the ED. Patient was evaluated by Dr. Gish and made a stroke alert. Dr. Salama saw the patient shortly thereafter. There were no objective findings on examination. CT head on my review showed only leukoaraiosis which was more than moderate in extent. CT angiography did not demonstrate a large vessel occlusion but did demonstrate bilateral carotid plaque with lipid rich features. Dr. Salama felt given the limited subjective findings that the patient was not a TPA candidate. He was admitted to observation under medicine and MRI brain was obtained. This demonstrated multiple small diffusion abnormalities in right hemisphere. To my eye these are suggestive of symptomatic carotid disease. Patient also obtained a MRI of the cervical spine which showed multilevel spondylyticchanges, none severe. Patient was discharged home with an increase in aspirin from 81 to 162 mg. He remained on 10 mg atorvastatin daily. He has an LDL of 100. The chart suggests that he has some concerns about taking statin. The patient's symptoms, CTA findings and MR findings indicate that this is symptomatic carotid disease. Care Timeline MRN: 2156168 Total (NIH Stroke Scale): 1 12/8/2017 Gish, Jonathan S, MD 1635  Arrived 1651  Point of Care Glucose ISTAT Troponin 1652  ISTAT Creatinine ISTAT GFR 1655  ISTAT TROPONIN (LABEL ONLY) Comprehensive Metabolic Panel (CMP) ISTAT Creatinine CBC with Differential Protime w/INR and PTT Extra Green Lithium Tube Hold Blood Bank Specimen 1702  CT HEAD STROKE ALERT 1705  XR CHEST AP PORTABLE STROKE ALERT 1708  Iohexol 60 mL CT ANGIOGRAM HEAD 1709  CT ANGIOGRAM NECK 1712  12 Lead EKG - Testing for ED 1854  Admitted to Observation

  17. Care Timeline MRN: 1114434 Total (NIH Stroke Scale): 1 12/9/2017 Adams, William H, MD 1046  Arrived 1052  ISTAT TROPONIN (LABEL ONLY) CBC Comprehensive Metabolic Panel (CMP) Prothrombin Time w/INR ISTAT Creatinine Hold Blood Bank Specimen 1054  ISTAT Troponin 1055  Extra Gold Top Tube ISTAT Creatinine ISTAT GFR 1058  12 Lead EKG - Testing for ED CT HEAD STROKE ALERT 1059  ISTAT Creatinine ISTAT GFR 1102  XR CHEST AP PORTABLE STROKE ALERT 1112  Ketorolac Tromethamine 30 mg 1114  DiphenhydrAMINEHCl 25 mg 1118  ProchlorperazineEdisylate 10 mg 1223  Magnesium, Serum Phosphorus, Serum 1300  Admitted This is a 36-year-old gentleman who was well on awakening but while in the shower prior to going to work he developed left sided numbness and confusion. He then developed right-sided headache. He was a prehospital stroke alert. He was evaluated immediately by Dr. Adams and very shortly thereafter by Dr. Salama. Dr. Salama found the patient had a very minimal motor deficit. A CT head demonstrated old strokes but no dense vessel sign. The patient has a prior history of strokes and a history of migraine. He also has a history of atrial fibrillation. He had undergone ablation which appeared successful but he was maintained on both apixiban and aspirin. MRI brain demonstrated a sizable right middle cerebral artery infarction. The patient had a prior extensive workup for causes of stroke. Prior events and in particular this event was consistent with migrainous stroke. Despite the size of the lesion on MRI, the patient went on to make a excellent recovery.

  18. History of recurrent infarctions began in 2009 and the most recent one was in October of this year. Most but not all of the events were associated with migraine

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