Case of the week – Stroke, TIA

THANK YOU TO MY PATIENT FOR GIVING ME WRITTEN CONSENT TO USE HER PHOTOGRAPH FOR EDUCATIONAL PURPOSES.

In the last post I discussed Bell’s Palsy.  One of the main concerns these patients have is whether or not they are suffering from a stroke.  The patient in the case had no features suggestive of stroke and the presentation was classical of post-viral Bell’s (7th Nerve) Palsy.  One of the key issues in the primary care setting is to be able to recognize this and reassure the patient accordingly, explain its benign nature and the high likelihood of recovery, yet that there is a small chance of persistent.  After this we must explain the treatment as outlined in the previous post and arrange to follow up the patient.

One of the differential diagnosis as mentioned is stroke/transient ischemic attack, and as we mentioned in these cases the forehead wrinkle test is spared, i.e. when the patient is asked to wrinkle his or her forehead she is able to wrinkle both sides.  This is because stroke lesions are usually unilateral and the clinical neurological features would be those of an upper motor neuron (UMN) deficit and with the forehead muscles, they receive motor nerve supply from both left and right motor cortex, so patients will still be able to wrinkle both sides of the forehead as they would be receiving motor input from the unaffected motor cortex.  But as with Bell’s Palsy their smile will be drooped and they will have difficulty with speech and swallowing fluids.

This week I saw a patient that gives us the perfect example of the difference with Bell’s Palsy and a UMN due to stroke, TIA.  She was kind enough to give written consent for her photograph to be used for our educational purpose.

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This patient presented with a history of sudden onset left-sided hemiparesis upon waking up that morning, difficult in speech (dysarthria), and drooping of her mouth all classical features of a right sided stroke/TIA lesion.  All such cases should be treated as an emergency and referred to a facility where there are resources to do appropriate investigations and management.

Strokes are usual involve either:

  1. A single penetrator or small vessel (lacunar syndrome) which are mainly give rise to specific focal neurological deficit.
  2. Cardio-emboli (heart to artery embolism) eg due to a cardiac arrhythmia causing a clot which can then dislodge and travel up to block the cerebral circulation.
  3. Large vessel to vessel embolic infarct
  4. Stroke can also be due to intra-cerebral hemorrhage due to bursting of one of the vessels and it is the differentiation between a thromboembolic infarct and a hemorrhagic infarct that is one of the key issues in deciding the specific treatment for stroke patients and this can only be reliable done using a CT or MRI scan not by clinical assessment.

In this case I advised the patient and her relative that they need to be referred to a facility with the appropriate resources available and suggested they go to PMGH.  I explained the cause (Stroke or TIA) and the possible outcomes, mainly that if it was TIA it will recover within 24 hours.  But either way she is now at an increased risk of further strokes and that at the primary health level, where I am, we will need to assess and address her various risk factors – eg – smoking, dibetes, cholesterol, sedentary lifestyle aggressively.

About Dr. Poyap J Rooney

Dr. Rooney is a medical doctor who has gained both his undergraduate medical degree and more recently his post graduate masters degree in clinical biochemistry at the University of Papua New Guinea.
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