Ischemic Stroke - Hennepin County Medical Center

Case Reports
Treating Ischemic Stroke:
Three Case Reports
Stroke is the leading cause of disability
in the U.S. and the third leading
cause of death. In the last fifteen
years, the advent of thrombolytic
drugs such as tissue plasminogen
activator (tPA) for ischemic strokes
has increased the range of options
for treating stroke patients. However,
because tPA and other options must
be provided within a specified number
of hours after symptom onset and
many complicating factors can occur,
stroke care remains a challenging
endeavor. The following case reports
describe diverse presentations and
care decisions for three recent
Minnesota ischemic stroke patients.
Case One
Management of middle cerebral
stroke with mass effect in the
setting of heparin-induced
thrombocytopenia
by Charles Bruen, M.D.
Department of Emergency Medicine
and Department of Internal Medicine
Hennepin County Medical Center
Abstract
The patient presented to the
Emergency Department with a large
right middle cerebral artery ischemic
stroke with an uncertain time of
onset. Significant edema developed,
leading to increased intracranial
pressure (ICP) and a midline shift.
This development was monitored via
a ventriculostomy and therapeutically
treated with cerebral spinal fluid
(CSF) drainage. The development of
Type II heparin-induced thrombocytopenia
(HIT) provided a challenge to
balance the new need for anti-coagulation
to prevent reactive thrombosis
from HIT with risk for hemorrhagic
conversion of the existing large
ischemic stroke. Lepirudin was used
to bridge anticoagulation until platelets
normalized and eventual warfarin
anti-coagulation was initiated.
Case report
The patient is a 53-year-old Caucasian
woman with a past medical history
significant only for fibromyalgia and
cessation of smoking ten years prior.
At approximately 3:00 a.m. the day
before presentation, she developed a
right-sided headache that woke her
from sleep. Several years earlier, the
patient had a similar headache that
resolved spontaneously.
The patient took ibuprofen for her
headache pain but had no relief. By
morning, her headache had worsened
to the point that she decided to stay
home from work. At midday, her husband
found her confused and disoriented,
with diarrhea on the floor and
objects in the home in disarray. Her
headache worsened all day, and by 8
p.m. that evening, her husband was
unsure of the patient’s ability to
understand what was told to her. By
the next morning, her husband noticed
weakness on the left side of her body
and the EMS system was activated.
On presentation in the Emergency
Department, the patient’s blood pressure
was 95/75, pulse 52, respirations
20, SpO2 98%. She was afebrile.
2 | Approaches in Critical Care | December 2008