Prepared by Dr Wong YL
Supervised by Dr Gordon Pang (Hospital Queen Elizabeth)
Mrs AJ, a 78 years old lady
Underlying
Atrial fibrillation
history of stroke with left hemiparesis in 2020 Presented with left sided body weakness noted at 6am associated with difficulty in talking Last seen well at 9pm before going to sleep Arrived in ED at 7.59am
Further history
Fall in sitting position when trying to stand up from bed upon awakening
Complained of pain over right hip and unable to ambulate
Medications-
T.Warfarin 3mg OD (last taken 2 days prior to admission)
T.Bisoprolol 5mg OD
T.Atorvastatin 40mg ON
Premorbid
Moderate frailty (Clinical Frailty scale 6)
ambulate with walking frame
Social history
Married with 8 children
Lives with daughter and son in law in single storey landed house with sitting toilet
Does not smoke or consume alcohol
Physical examination
Glasgow Coma Scale E4V2M5
Blood pressure 129/96mmHg Pulse rate 118 beats per minute Temperature 36.7◦C Oxygen saturation 100% on NPO2 2L/min Dxt 8.8
Neurological examination
Tone hypertonia left U/L and L/L
Power 4 for right upper limb, 1 for left upper and lower limb(unable to assess power of right lower limb due to pain)
Reflexes hyperreflexia left upper and lower limb
Barbinski upgoing left side • Unable to assess sensation NIHSS more than 15 Right lower limb
Bruises over right thigh
Tenderness over right hip
Dorsalis pedis pulse palpable
Investigations
ECG Atrial fibrillation
Chest Xray clear lungs field
MRI Brain- Hyperacute infarcts seen at right frontal and right side of pons, acute infarct seen at right cerebellum. Right parietooccipital and left frontotemporal encephalomalacia
MRA brain - Vessel occlusion at distal basilar artery and M4 segment right MCA
Pelvic xray- right neck of femur fracture
Pelvic X-Ray
MRI Brain
Blood investigations
Full blood count - WCC 6.55 Hb 7.1 Plt 296
Renal Profile - Urea 7.7 Creat 94.9 Na 139 K 4.1
Liver Function - Test Alb 36 ALP 74 ALT 16
Coagulation profile - INR 1.26
Discussion
Should the patient be considered for thrombolysis ?
With concomitant acute stroke and hip fracture, should the patient be offered operative management for the hip fracture?
If yes, what is the appropriate timing for the surgery?
Patient will benefit from perfusion imaging to determine whether this wake-up stroke will benefit from thrombolysis/thrombectomy if expertise is available. NIHSS still within limits to reap benefit. INR not high to be contradicted as well. There is also a Japanese study stating benefit from reduced dose alteplase with borderline high NIHSS.
This article also talking about thrombolysis in those on DOAC
https://www.ahajournals.org/doi/10.1161/JAHA.122.027238
Will need at least 48hours if thrombolysed to assess situation--> if develop complications eg ICB--> would not advocate for hip surgery --> palliate
if improving and has potential to ambulate--> may then consider emergency op with high risk consent and ICU backup. However, this should be a MDT and shared decision making process after family conference.
Well done on finding such a clinical dilemma. In view of the use of warfarin and hip fracture and the size of the stroke, thrombolysis will be contraindication, particularly as this is a wake up stroke, last awake 9 hours prior. Hip fracture surgery in this case would also be a major issue, and one would question the wisdom on not thrombolysing but operating. The prognosis for this patient is guarded, and it would require around 24 hours of stabilization, can shared decision making with regards to surgery. Palliative care should be considered if her clinical condition does not improve.
The data on IVT in posterior circulation stroke is limited, her premorbid condition suggests that she is frail. The role of thrombolysis in her condition is limited. Given the previous insults to her brain, any neurological recovery if at all might be small with high risk of ICH.
In cases of acute stroke and hip fracture, a multidisciplinary team involvement is necessary. Careful discussion with anaesthetist and surgeon and family is needed. Surgery will be deemed high risk with ICU back up.
Elective surgery post thrombolysis should be delayed at least 6 months. Emergency surgery should be done if needed.