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1. A Case Presentation on Cerebrovascular Accident Date: 27 th May 2019 Venue: GMCH Lecture Hall Complex Moderator : Dr. Madhumita Priyadarshini Das Professor Department of Medicine Gauhati Medical College & Hospital

2. Presented by Roll No. Name 36 Bishal Ray Baruah 37 Ankita Sen 38 Udipta Bhuyan 39 Annisha Kalita 40 Deba Protim Bora 41 Parag Thakuria 42 Sourav Sankar Dutta

3. Patient Particulars Name- Sailen Mandal Age-55 years Sex-Male Religion-Hinduism Occupation-Farmer Education status- Illiterate Address- Vill - Laukhua Dist-Nagaon Date of admission- 21-04-2019 Date of examination-22-04-2019

4. Chief Complaints 1. Weakness of left side of the body for last 1 day. 2. Slurring of speech for last 1 day. 3. Deviation of angle of mouth towards right side for last 1 day.

5. History of present illness The patient complains of weakness of left side of the body for last 1 day. It was sudden in onset and began on the evening of 21 st April while he was taking a bath. The patient felt weak, could not stand steady, and lied down on the bed and called out for help. The weakness was progressive in nature and initially involved the muscles of lower limb affected followed by that of the upper limb. The weakness progressed from proximal part of the affected limb towards distally as evident by his inability to lift his arm or stand steady but subsequently could not move his wrist or wear slippers. The weakness completed within 2-4 hours and by that time he had completely lost all of his movements on the left side. The weakness was associated with headache which was sudden in onset, started along with the onset of weakness, located diffusely over the head, moderate in severity, dull aching in character and persistent in nature. No history of vomiting was present.

6. History of present illness He also complains of slurring of speech which began concurrently with the weakness. However he has no difficulty in understanding and answering the questions put to him. He complains of deviation of his angle of mouth towards the right side first noticed by his family members which becomes more prominent while talking. He finds difficulty in chewing food. However there was no difficulty closing his eyes and he could perceive the taste sensation.

7. History of present illness The patient does not complain of similar weakness on right side of the body and he could feel the clothes he is wearing even on his affected side. There is no history of any fever, abnormal body movements, loss of consciousness, abnormal behavior, blurring of vision, vertigo, dizziness, stiffness in the neck at the onset or later . He does not complain of abnormal perception of sense of smell, vision difficulty, facial numbness, nasal regurgitation of food, swallowing difficulty or hoarseness of voice. His urine is normal in amount, frequency and colour . No complaint of urinary incontinence or retention. Bowel habits are not altered, appetite and sleep is normal. There is no history of recent weight loss. He is hypertensive for the last 7 years and is irregular on medications but is non diabetic.

8. Course during hospital stay Since admission no new symptoms have developed. Paralysis was complete at the time of admission has not improved during the course of hospital stay . Medication has been started, however, slurring and deviation of angle of mouth is persistent and no improvement is seen.

9. Past history There is no history recent head trauma, similar weakness or transient loss of consciousness in the past . No complaint of spontaneous bleeding from any site or intake of anticoagulants. He does not gives history of breathing difficulty, chest pain, palpitation rheumatic fever or easy fatigability. No complaint of cramping pain in the leg.

10. Personal history Prior to illness the patient used to consume a non vegetarian diet consisting of 3 major meals and 2 minor meals every day. There is no history of alcohol, smoking, drug abuse, chewing tobacco but chews betelnut occasionally.

11. Family history The patient’s family comprises of his wife, three sons and one daughter. No other significant family history is present.

12. Other history Socio-economic history The patient belongs to lower middle class family with per capita income of Rs 3000 per month. He lives in kucca house with 5 rooms, a separate kitchen and a sanitary latrine. Source of water is from tubewell which is consumed after filtration. Drug history The patient takes medication of hypertension irregularly for last 7 years. No history of intake of any other drug like anticoagulants, amphetamines etc.

13. Other history Allergy history The patient is not known to be allergic to any inhalant , ingestant or contactant. Immunization history The patient could not recall any history of immunization. However, BCG scar was seen.

14. Physical Examination

15. General Examination Appearance : The patient looks ill Consciousness : Alert, conscious, cooperative and oriented to time, place and person. Decubitus : In supine position Built : Average Weight -60kg BMI -20.76kg/m2 Height -170 cm Nutrition : Fair Pallor :Absent Icterus : Absent Cyanosi s: Absent

16. General Examination Condition of skin and hair: Graying of hair Oral cavity: Poor hygiene Teeth: Teeth stained with dental caries Tongue: Pink,moist with normal papillae seen. Neck glands: Not palpable Neck veins: Not engorged Clubbing : Absent Koilonychia : Absent Oedema : Absent Dehydration : Absent

17. General Examination Pulse: Rate- 78 bpm Rhythm- regular Volume- normal Character- normal Condition of the arterial wall- normal No radio-radial or radio-femoral delay All peripheral pulses are bilaterally and symmetrically palpable Blood pressure - 150/90 mm Hg in the right arm taken in supine position Respiratory Rate - 18/min, Regular, abdomino -thoracic type Temperature - 98.4 F

18. Systemic Examination

19. Central Nervous System Examination: 1. Higher functions Appearance: Looks ill Behaviour : Cooperative Consciousness: The patient is conscious, alert and oriented to time, place and person. GCS =15/15 (E4V5M6) Emotional status: Normal Memory: Intact Intelligence: Normal. Language and speech: Unable to speak fluently Handedness: Right handed

20. 2.Examination of cranial nerves Cranial Nerves Examination Findings I Sense of smell on each nostril Normal II Visual Acuity Visual field Colour Vision Normal in both the eyes III, IV, VI Ocular movements and pupils. Light Reflex Accommodation Reflex Normal in both the eyes. V Motor function Sensory function Corneal reflex Jaw jerk Normal

21. Cranial Nerves E xamination Findings VII Nasolabial fold Angle of mouth Epiphora Muscles of Facial expression Taste on anterior 2/3rd of tongue Flattened on left side. Deviated to right side. On left side Weakness of Buccinator on left side. Present VIII Tuning Fork Test: Rinne’s test Weber’s test ABC test Normal in both ears. Centralized. Normal in both ears. IX and X Soft palate Pharyngeal or gag reflex Taste sensation on posterior 1/3 of tongue Not deviated Normal Normal XI Power of sternocleidomastoid and trapezius muscle Couldn’t be tested XII Power of tongue muscles Deviation Size and shape Movements Normal. No deviation. Normal. No abnormal movements seen

22. 3. Examination Of Motor Function: 1.Muscle bulk: Normal in both sides, no wasting present. 2. Muscle tone: 3. Muscle Power: Tone Right Left Upper Limb Normal Spastic Lower Limb Normal Spastic Grade Right Left Upper limb Grade 5 Grade 1 Lower limb Grade 5 Grade 1

23. 3. Limb co-ordination: 4.Involuntary movements: No fasciculations or any other abnormal movements seen. Test Right Left Upper Limb (Finger-nose test) Normal Could not be tested Lower Limb (Heel-shin test) Normal Could not be tested

24. 4. Sensory system Superficial ( pain,touch,temperature )- Normal on both sides. Deep (vibration, position sense, pressure sensation and proprioreception )- Normal on both sides. Cortical ( stereognosis,tactile localization and two-point discrimination)- Normal on both sides.

25. 5. Reflexes Deep tendon reflexes Right Left Biceps jerk Normal Brisk Triceps jerk Normal Brisk Supinator jerk Normal Brisk Knee jerk Normal Brisk Ankle jerk Normal Brisk Superficial reflexes Right Left Abdominal reflex Normal Absent Plantar reflex Flexor Extensor

26. Primitive reflexes: Absent. Clonus : Patellar clonus : Absent Ankle clonus : Absent

27. 6. Other examination: Stance and Gait : Could not be assessed. Signs of meningeal irritation : Neck rigidity: Absent Kernig’s Sign: Negative Cerebellar Functions: Couldn’t be assessed Cranium and spine: Normal Autonomic function: Bowel and Bladder: Normal

28. Cardiovascular Examination Inspection: Precordium is normal. No bulging or visible pulsations are seen . Palpation: Apex beat is felt in the 5th intercostal space just medial to the mid- clavicular line . Auscultation: 1st and 2nd heart sounds are heard normally. No additional heart sounds are heard

29. Gastrointestinal Examination Inspection: Shape and size of abdomen is normal. No visible pulsation and scar mark present. Umbilicus is inverted and in the midline. Hernial sites are intact Palpation: Superficial Palpation- No raised temperature ,No tenderness, no palpable lump. Deep Palpation- Liver-Not palpable Kidney- Not palpable Spleen- Not Palpable Percussion : Upper border of Liver dullness present at 4 th intercostal space. Tympanitic note over the abdomen. Fluid thrill and shifting dullness absent. Auscultation: Bowel sounds heard.

30. Respiratory Examination Inspection: Shape and size of chest is normal. Movement of chest is bilaterally symmetrical. Palpation: Trachea is in the midline. Chest expansion is normal. Vocal fremitus is bilaterally same and normal. Percussion : Lung field is uniformly resonant in all areas. Auscultation: Normal vesicular breath sounds are heard and no additional sounds are heard. Vocal resonance is normal on both sides

31. Provisional Diagnosis The case is provisionally diagnosed to be stroke with left sided hemiplegia and upper motor type of facial palsy without sensory and autonomic involvement, probably of hemorrhagic etiology possibly due to systemic hypertension .

32. Differential Diagnosis Ischemic stroke: Thrombotic or embolic Subarachnoid haemorrhage Stroke mimics 1. Functional mimics: -Encephalitis - Todd’s palsy - Metabolic encephalopathy like hypoglycemia - Focal seizures - Conversion disorder 2.Structural mimics: -Intracranial tumour - Cerebral abscess - Demyelination

33. Investigations

34. Investigations 1. HAEMATOLOGY WBC : 7.62 x 10 3 /microliter Hemoglobin: 14 gm/dl Platelet : 130x 10 3 /microliter DLC : Neutrophil : 71 % Lymphocyte : 14.6% Monocyte: 6.8% Eosinophil: 7.3% Basophil: 0.3 % ESR : 10 mm at the end of first hour PT : 14.1s ( 12- 16) INR : 1.08 aPTT : 30s ( 28 - 44)

35. Investigations 2. BIOCHEMISTRY Glucose – random 106 mg/ dL (80-120) Urea 26.4 mg/ dL (19.26-42.8) Creatinine 1.1 mg/ dL (0.66 – 1.25) Sodium 139 mmol /L (137-145) Potassium 4.3 mmol /L ( 3.5-5.1) TSH 1.80 mIU /L (0.46 -4.68) Total bilirubin 0.8 mg/dl (.2-1.3) S. Albumin 4.6 g/dl (3.5-5.5) Lipid profile HDL = 51 mg/dl, LDL=110 mg/dl, TG= 128 mg/dl 3. ECG : Normal sinus rhythm.

36. Investigations 4. Radiological investigation : Non contrast CT examination of head showing hyperdense area in the right capsuloganglionic region suggestive of haemorrhage with a surrounding area of low attenuation representing brain oedema or exudated serum.

37. Final Diagnosis The patient is diagnosed to be a case of intracerebral hemorrhage involving the right capsuloganglionic region with left sided complete hemiplegia and left sided upper motor type of facial palsy .

38. M anagement

39. AIM- 1) Minimising brain damage 2)Preventing complications 3)Disability limitation and rehabilitation 4)Reducing the risk of recurrance .

40. General management 1.Airway :keep patient NPO if swallowing unsafe or aspiration occurs. Endotracheal intubation and ventilation if GCS<8 /risk of aspiration is present. 2.Breathing: check respiratory rate and O2 saturation and give supplemental O2 if saturation < 95%. 3.Circulation : check peripheral perfusion, pulse and BP and treat abnormalities with fluid replacement ,anti-arrhythmic and inotropic drugs as appropriate.

41. General management 4. Hydration : If signs of dehydration, give fluids parenterally or via nasogastric tube. 5. Medication : if patient is dysphagic, consider alternative routes for essential medications. 6. Nutrition: assess nutritional status and provide nutritional supplements if necessary. If dysphagia persists >48 hrs, start feeding via a nasogastric tube.

42. General management 7 . Pantoprazole :for prevention of stress ulcers. 8. Hyperthermia or hypothermia : evaluate and treat accordingly. 10.Incontinence : check for constipation and urinary retention, treat appropriately. Avoid urinary catheterisation unless patient is in acute urinary retention or incontinence is threatening pressure areas. 11. Pressure areas: Treat any local infection Turn immobilised patients regularly Provide pressure relieving mattress

43. General management 12. Blood glucose : check blood glucose regularly. If elevated (>11.1mmol/l or >200mg/dl), should be managed with insulin infusion or glucose/potassium/insulin (GKI) If hypoglycemic , 25 ml of 50% glucose slow IV bolus should be administered.

44. Specific management 1.Mannitol (20%) 100ml IV infusion TDS- to reduce cerebral oedema . 2.Control of BP : I n previously hypertensive -if BP > 180/105 mmhg ,should be reduced to 160/100 mmhg In previously normotensive - ifBP >160/95mmhg ,should be reduced to 150/90mmhg Drugs used- a) inj. Labetalol 1 amp in 100ml NS IV b)tab. Amlodipine 5mg OD

45. Advice on discharge Speech therapy Physiotherapy Lifestyle modifications – Avoid s moking Lower salt intake Lower fat intake Avoid excess alcohol intake Exercise Maintain ideal body weight

46. Prognosis and Summary

47. Prognosis Total ICH score 30 day mortality 1 13 2 26 3 72 4 97 5 100

48. SUMMARY My patient Sailen Mandal , a 55 year old right handed Hindu male presenting with the chief complaints of weakness of the left side of the body for 1 day, slurring of speech for 1 day, deviation of angle of mouth to the right side for the last 1 day. The paralysis was complete associated with moderate headache not associated with convulsions or loss of consciousness. There is past history of hypertension for the past 7 years with irregular medication. No significant findings on general examination .

49. SUMMARY On systematic examination higher functions are normal, cranial nerves except facial nerve are intact. Motor examination reveals hypertonic left sided muscles. Deep tendon reflexes are brisk on left side and superficial plantar response is of extensor type in the left foot. Radiological examination reveals hyper dense area in the capsuloganglionic region suggestive of haemorrhage

50. SUMMARY The patient is diagnosed to be a case of intracerebral hemorrhage involving the right capsuloganglionic region with left sided complete hemiplegia and left upper motor type of facial palsy. The case is managed by general measure to maintain airway, breathing, respiration, hydration and specific measures like mannitol and reduction of systemic BP. Surgical intervention might be required if the bleed area increases in size.

51. Thank You.