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Clinical Case Presentation September 2023

Prepared by: Dr Mohd Zulkifli Bin Mohamad Zahir

Supervisor: Dr.Rizah Mazzuin Razali

Current posting: HKL


Case Scenario

73 y.o Mr.AS Malay Male


Underlying

  • DM

  • HPT

  • RIght Lacunar Infarct with residual mild Left Hemiparesis

  • IHD– 3 vessels disease done PCI

Meds

  • T Diamicron MR 30mg OD

  • T Amlodipine 5mg OD

  • T Cardiprin 100mg OD

  • T Atorvastatin 20mg ON

Premorbid ADLs and social background

1. iADLs

  • Still working as a kindergarten operator

  • Able to drive his car from KL– Penang by himself to manage his company

  • Meds, finances – managing these by himself

2. bADLs

  • Independent for bathing, dressing, personal hygiene, toilet, mobility, transfer, feeding

3. Social history

  • Lives with wife in a landed house–bungalow type, single storey

  • Has 3 children

  • Denies cigarette smoking/alcohol consumptions

Case History

  • Initially admitted for 5 days with Right Frontotemporoparietal lobe bleed and fall

  1. Fell in the bathroom – event unwitnessed

  2. Developed dysphagia, worsening left sided hemiplegia, treated conservatively

  3. Upon discharged, patient had become dependent in all care

  4. Initial CT Brain Report : Right frontotemporal parietal bleed

  5. No expansion of bleed upon repeated CT scans

  6. Cardiprin discontinued upon discharge

Case History

  • Readmitted to hospital 1 week post discharge

  • Presented with productive cough, fever and hypoactive delirium

  • Vital signs upon arrival

• BP : 140/70, HR 85, Temperature : 38.1, SpO2 97% under Room Air

  • No new neurological deficits, power 0/5 over Left Upper and Lower Limbs

  • Treated as Hospital Acquired Pneumonia

  • Completed 1 week of IV Tazocin 4.5g QID

  • Blood C&S : no growth

  • Repeated CT Brain at 2/52 post ICH event :

• Recent right MCA territory infarct with haemorrhagic transformation

  • CECT and CTA Brain at 4/52 post event :

• Right cerebral hemisphere rim enhancing lesions associated with gyriform enhancement, represent post infarct

• Residual Right temporal intraparenchymal haemorrhage


Case Progress

  • Plain CT Brain at 6/52 post event

• Residual haemorrhage at medial aspect of Right temporal lobe, reducing in size, measuring 0.4 x 0.6cm ( previously 0.5cm x 1.0cm)

• No new acute intraparenchymal haemorrhage

• Right MCA territory infarct with haemorrhagic transformation

  • Patient was subsequently transferred to Hospital Rehabilitasi Cheras for further period of rehabilitation

  • Medications list upon transfer

  1. Syp lactulose 15 mls tds

  2. Tab Calcium Carbonate 500 mg bd

  3. Tab Calcitriol 0.25mcg od

  4. Tab Bisoprolol 1.25mg OD

  5. Tab Linagliptin 5mg OD

  6. Tab Atorvastatin 20mg ON


Investigations

Investigations

  • ECG


Investigations

  • Echo

  1. Ejection Fraction 40%, anteroseptal and inferior posterior hypokinesia

  2. Normal LA size

  3. No thrombus

Physiotherapist Assessment

  • Elderly Mobility Scale : 2/20 -> 4/20 -> 6/20

  • Bed mobility - independent rolling side to side

  • Sitting up : mod to max assist

  • Transfer : mod assist -> stand transfer with consistent cue

  • Sit to stand : pull to stand with mod assist -> push to stand using quadripod

  • Sitting balance – good for both static and dynamic

  • Standing balance - Static : fair, Dynamic : poor

  • Ambulation - Quadripode, need constant verbal cue

Occupational Therapist Assessment

  • Upon transfer to HRC (3 weeks post ICB event)

  1. Modified Barthel Index (MBI) :27/100

  2. Required maximal assistance for bADL

  3. MMSE : 27/30

  • 1st week rehab

  1. MBI : 32/100

  2. Maximal assistance for bADL

• Improvement in dressing, now requiring moderate assistance

• PU/BO – in diapers but able to indicate


  • 2nd week rehab

  1. MBI : 37/100

  2. Improvement in ambulation – with quadripode


Speech Therapist Assessment

  • Meal observation done – no issue, some oral residue, requiring multiple swallow. Thus, need to remind patient

  • Speech: ok but poor respiration and prosody(intonation)

  • FEES : soft, moist diet and thin liquid with spoon

Points to ponder


  • The above figure is an image of his plain CT Brain at 2/52 post haemorrhagic event What is/are your differentials based on the image?

  • Based on the MDT assessment, outline the geriatric issues for the above case.

  • What are the risk factors for future fall in this patient’s case?

  • How do you mitigate the risk of a future CVA event?

  • What is/are the best approach for deciding to anticoagulate this patient?



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3 Comments


CT shows hyperdense area with bleeding into the lesion suggestive of infarct with bleed or bleeding into a glioma. MRI may help.

Before anticoagulation, the risk and benefits need to be considered and this needs to be discussed with the family. The risk of falls is high due to stroke, diabetes and medications (OHG). OT, PT and nutrition support should be continued and attempts must be made to avoid hypoglycaemia and postural hypotension.

Sarath Lekamwasam

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  1. hyperdensity represents intraparenchymal bleed with surrounding cerebral oedema and midline shift; need to differentiate cytotoxic oedema with vasogenic oedema caused by SOL (tumour/abscess)

  2. a. Cardioembolic stroke (AF/flutter) R MCA infarct with hemorrhagic transformation

b. possible thyrotoxic cardiomyopathy (HFmrEF) ddx ischemic

c. Deconditioning

d. Hypoactive delirium due to infection/recent stroke, post stroke cognitive impairment

e. Recent fall

3. stroke, cognitive impairment, sarcopenia, (postural hypotension not mentioned)

4. SPAF using DOAC after resolution of bleed, good glycemic and BP control

5. HASBLED 3- ensure good BP control while avoiding postural hypotension, ongoing outpatient rehab to mitigate falls risk (PT), close supervision while ambulating, home fall hazard assessment (OT), sensible footwear, shared decision making with caregiver re: decision for DOAC


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1.CT brain got midline shift and looks like fingerlike projection like think need to rule out brain tumor/ vasogenic edema


1.MCA infarct with hemorrhagic transformation likely due to paroxysmal Af secondary to hyperthyroidism (cardioembolic)

with left hemiparesis n dysphasia


2.heart failure reduce EF due to ischemic cardiomyopathy


  1. CHADSVAS- 6- need to discuss with him n family regarding Choice of anticoag risk of bleeding vs benefit recurrent stroke( rpt scan make sure no bleeding prior starting)-individualised and timing of anticoag NOAC therapy- rather than follow diener law (https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.036695)

  2. treat the hyperthyroidism

  3. optimise pillars of heart failure treatment

  4. nutrition( dietician) and regular PT OT

  5. Education on diet modication and technique (speech)- reduce risk of aspiration pneumonia

  6. Monitor emotion- depression/ agitation( affect Frontal/…


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