Ischemic Stroke - Hennepin County Medical Center

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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
Case Reports The patient was awake, alert, oriented to person, place, and time, maintaining her airway, and breathing spontaneously. She had 2+ distal pulses. She was moving her right arm and both legs, but her left arm was held at her side. The patient had 5/5 strength in all extremities except her left upper; she was unable to lift her arm off the cart, was not able to grip, and was not able to perceive touch. The remaining physical exam was normal. Figure One. CT scan obtained on presentation to the Emergency Department. Figure Two. CT scan obtained after placing ventriculostomy on hospital day 3. Figure Three. CT scan obtained the day prior to discharge after 39 days in the hospital. The patient was given one liter of normal saline and Dilaudid for pain. A computed tomograph (CT) scan of her head without contrast was obtained. (See Figure One.) The images revealed a well-established hypodensity in the distribution of the right middle cerebral artery. Also noted was a significant associated edema-induced mass effect and approximately 6-7 mm of right-to-left midline shift and mild sub-falcine and uncal herniation. Immediately following the patient's return from radiology, she was started on Dilantin for seizure prophylaxis; 5% hypertonic saline was started to prevent further midline shift. The decision was made not to treat with thrombolytics and to treat the edema conservatively in the Surgical Intensive Care Unit (SICU). The patient was closely followed by the neurocritical care and neurosurgery team members. Serial CT scans revealed an evolving hypodensity with extensive edema. (See Figure Two.) Concerns about increased ICP prompted the placement of a ventriculostomy. The initial ICP was 20 mmHg. Blood pressure was controlled with a mean arterial pressure (MAP) >70 mmHg and systolic blood pressure (sBP) 320 osmols. She was placed on deep venous thrombosis prophylaxis with heparin. Over the next several days in the SICU, repeated attempts at clamping the ventriculostomy were poorly tolerated by the patient; when this was attempted, changes were noted in her mental status and her ICP increased to 25-40 mmHg. Mechanical drainage of CSF (averaging 200cc per day) would return the ICP to less than 10 mmHg. During the period of peak ICP measurements on days three through nine, a combination of 3% hypertonic saline and CSF drainage was used, with the goals of maintaining ICP 60 mmHg, and sodium
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Ischemic Stroke - Hennepin County Medical Center

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