Published 26 November 2008, doi:10.1136/bmj.a2427
Cite this as: BMJ 2008;337:a2427

Endgames

Case report

A case of right sided weakness

¹ Department of Stroke Medicine, King’s College Hospital, London SE5 9RS

A 77 year old right handed man presented with a history of resolving right sided weakness. His right arm and leg were affected, and his arm felt "heavier" than his leg. His wife noticed that his face drooped on the right side and that he used the "wrong words" when speaking. Within an hour of admission his weakness completely resolved, and a transient ischaemic attack was diagnosed.

Forty eight hours after presentation, the patient re-presented to the accident and emergency department. He was reviewed by a trainee doctor (foundation year 2). He had a dense right sided hemiparesis, his right arm was worse than his right leg, and he had "forehead sparing" facial weakness. He was dysphasic, with his gaze preference to the left. His pulse was regular at 90 beats a minute and his blood pressure was 140/90 mm Hg. He had no clinical signs of meningism. His symptoms had been present for 30 minutes and had not improved.

Questions

1 What relevance does the initial presentation of transient ischaemic attack have on the risk of subsequent events?

2 On re-presentation, which accident and emergency clinical decision tool should be used?

3 What should be the immediate management plan?

4 Where should he be managed?

5 What should you do if swallowing is impaired?

Answers

Short answers

1 The risk of stroke after a transient ischaemic attack is as high as 31.4% at seven days.¹

2 The recognition of stroke in the emergency room tool (ROSIER).

3 Review by a senior clinician, urgent computed tomography of the brain, and consideration for thrombolysis.

4 The stroke unit.

5 Consider nasogastric feeding and urgent assessment for speech and language therapy.

Long answers
1 Transient ischaemic attack and risk of stroke
Transient ischaemic attack is not a benign diagnosis. This patient seems to have had a transient ischaemic attack that affected the left middle cerebral artery. The national clinical guidelines for stroke are clear about the importance of prompt management of patients with transient ischaemic attack.² Such patients should be assessed and investigated in a specialist clinic as soon as possible within seven days.^{3 4 5} Their risk should be assessed using an appropriate scoring system, such as the ABCD2 score (table 1).⁶ This seven point score is calculated on the basis of age, blood pressure, clinical features, diabetes, and duration of symptoms. Large population based studies have shown that people with a high score have up to a 31.4% risk of stroke within seven days.¹ Risk factors for cerebrovascular disease should be treated appropriately in these people. The non-randomised EXPRESS study found that an early package of medical interventions—such as management of blood pressure, antiplatelet agents, and a statin—was effective.⁷ Patients with symptoms of anterior circulatory stroke may be suitable for carotid endarterectomy. Early identification of these patients is important (via Doppler ultrasound, computed tomography, or magnetic resonance imaging). This is because analysis of pooled data from two large randomised control trials (North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST)) found that the five year absolute risk reduction in ipsilateral ischaemic stroke and operative stroke or death was significant only if the patient had a carotid endarterectomy within two weeks of their last event.^{8 9} Our patient had a regular pulse, but this should be confirmed by electrocardiography. Electrocardiographic monitoring should be carried out for longer if paroxysmal atrial fibrillation is suspected because this condition is an undertreated risk factor for strokes, and if present the patient should be considered for anticoagulation.^{10 11}

View this table: [in this window] [in a new window]   Table 1 ABCD2 score for assessing the risk of stroke after a transient ischaemic attack

 
2 Decision tools
Many tools have been developed to facilitate early diagnosis and rapid acute thrombolytic treatment of acute ischaemic stroke. These include FAST (face, arm, speech test),¹² LAPSS (Los Angeles prehospital stroke scale),¹³ ROSIER (recognition of stroke in the emergency room),¹⁴ MASS (Melbourne ambulance stroke screen),¹⁵ and CPSS (Cincinnati prehospital stroke scale).¹⁶ We recommend the ROSIER scale, which incorporates glycaemic control, seizures, and levels of consciousness, because it has the highest positive predictive value and sensitivity of all these scales (table 2).

View this table: [in this window] [in a new window]   Table 2  Tools for early diagnosis of acute ischaemic stroke

 
3 Management plan
This patient is having an acute stroke. This is a medical emergency. Older evidence indicates that the patient should be examined by "an experienced clinician,"^{17 18} so discussion with a senior doctor would be important. However, this evidence pre-dates the introduction of acute thrombolysis, so discussion must not delay treatment unduly. The nature and time of onset of the neurological deficit should be clearly documented.

Thrombolysis should be considered for this patient because his symptoms are of less than three hours’ duration.¹⁹ Alteplase is recommended for thrombolysis in the United Kingdom.²⁰ The patient should be sent for urgent computed tomography of the brain to exclude intracerebral haemorrhage.

If the patient does not undergo thrombolysis, aspirin 300 mg should be given orally, rectally, or via a nasogastric tube. If the patient is treated with thrombolysis, aspirin should be delayed for 24 hours.^{21 22 23 24}

4 Where should he be managed?
A systematic review of randomised trials showed that the stroke unit is the best place to manage patients with stroke. For every 100 patients managed on a stroke unit versus a non-stroke unit, five more returned home, four fewer died, and three fewer ended up in institutional care. Stroke unit care is also associated with an absolute increase in "good" outcomes without a substantial increase in dependent survivors. The benefits apply to all patient groups.²⁵

5 Impaired swallowing
Impaired swallowing is common after stroke and has been reported in up to 40% of patients in the acute phase.²⁶ Medical or nursing staff should perform a swallow assessment on admission and instigate speech and language therapy promptly in the absence of a normal swallow. In the acute stroke period nasogastric administration of drugs, fluids, and nutrition is often useful. However, randomised controlled trials indicate that early insertion of percutaneous endoscopic gastrostomy tubes is not associated with better outcomes,²⁷ and such tubes should not be inserted until after the acute phase of the stroke.²⁸

Cite this as: BMJ 2008;337:a2427

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent obtained.

References

1. Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 2005;366:29-36.[CrossRef][Web of Science][Medline]
2. Royal College of Physicians. National clinical guidelines for stroke. 2nd ed. Prepared by the Intercollegiate Stroke Working Party. London: RCP, 2004.
3. Lovett JK, Dennis MS, Sandercock PA, Bamford J, Warlow CP, Rothwell PM. Very early risk of stroke after a first transient ischemic attack. Stroke 2003;34:138-40.[Abstract/Free Full Text]
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