Case: Stroke-like symptoms with headache

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Zebra Hunter

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Case:

70+ yo F w/ hx of CVA 7yrs prior w/ residual mild expressive aphasia presents w/ severe expressive and receptive aphasia and severe headache. Onset 1hr prior to arrival, and the onset was actually witnessed by family member. The family member at bedside states she went from calmly eating her breakfast to placing her head in her hands in obvious, severe discomfort with an inability to communicate. The only thing the patient can clearly state without much provocation is that "it hurts" while pointing to her head. The patient has no history of headaches. She does have a hx of HTN and DM. She is not on any anticoagulation. She does take a baby aspirin daily, no plavix.

VS: HR-92, BP-155/100, RR-16, Temp-98.2 (Glucose: 105)

Physical exam
General: Alert but in moderate distress
HEENT: EOMI, PERRL, all otherwise unremarkable
CV: RRR, no murmur, 2+ pulses in all extremities
Resp: Unremarkable
GI: Unremarkable
Skin: unremarkable
Neuro: A&O to person only, unable to state current month or year, where she is at, or why she is here in hospital. Patient has difficulty following simple commands requiring multiple attempts before she is able to comprehend the command that is asked. She has significant difficulties communicating. No dysarthria. She has 3/5 strength in RLE and 4/5 strength in all other extremities. Patient does localize to pain b/l, but unable to communicate for accurate sensory exam.

Imaging
CT head: L sided old infarct, otherwise, no evidence of bleed or acute changes

What are you doing next?

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Tricky. Seems more like headache with neuro deficit. Headache is a different workup. Some would say your CT is probably sufficient. Others would say if your clinical suspicion is high enough, CT is insufficient and another test must be done.

Or it's a stroke, and you're going to get an email about your door to lytic time for stalling to use your doctor brain.
 
TPA for acute stroke. Then ct angiogram head and neck.
 
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sudden onset headache and neurologic symptoms.......I would seriously consider LP before giving lytics.

If it is a burgeoning SAH, and you give the tpa........dead!

Strokes don't hurt.
 
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I'm assuming you're not withholding an interesting physical finding like an abnormal anterior chamber (glaucoma) or early shingles. While I'm thinking outside the cranium, I'd probably check a carboxyhemoglobin.

But mainly I'm concerned about dural sinus thrombosis or a new CVA, possibly in the posterior fossa that's causing some swelling-->headache. A small aneurysm is also on the differential.

So I think I'd hold tPA until at least getting a CT angiogram. Preferably I'd get an MR angiogram+ a look at the dural sinuses.
 
Hrm, I'd probably buzz her through the CTA with IV contrast of head/neck (not waiting for Cr results), and base my TPA utilization off of that study.

Certainly I have seen run-of-the-mill ischemic MCA strokes (and thalamic infarcts) where the patient c/o significant headache. Not the USUAL presentation, but it happens.
Of course in this case one might worry about dissection (pain + defects).
I've seen migraine do this, but rather uncommon randomly in an older person.
I do rather doubt SAH significant enough to cause neuro defects UNSEEN on a non-con head CT...
 
drug use???

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Don't let the fact that there's "pain" talk you out of thinking there's a brain infarct of some sort. Sure, infracting brain matter doesn't feel pain, but an offending vessel can.

A dissected carotid, vertebral or cerebral artery can hurt, clot, then cause an infarct. So can a popped aneurysmal vessel, as others mentioned above.

A new central neuro deficit plus pain should make you think "vascular." Aortic dissection can cause pain, also, and send clots central. Vertebral, carotid (neck pain) cerebral (head pain) etc. A hemorrhagic bleed, also (obviously) can cause pain.

Take home point: When stroke symptoms are accompanied by pain, work it up as a stroke as you normally would, PLUS think about the red tubes from chest to neck to noggin. Torn bleeding vessels won't be as happy you've given them blood thinners/tPA as some lawyer certainly will be.
 
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tough call, recently went to a neuro lecture about the residual problems, not the acute presentations of stroke. in retrospect he quoted up to 50% ischemic stroke had a headache. you're 1 hr in, still have a little time. cta head w/wo and go from there. discuss w family tpa option stroke vs early sah.

how'd the pt turn out?
 
Not withholding any physical exam findings (interestingly enough, I did have my first acute angle closure glaucoma who actually presented as a headache, and did not specifically state it was truly eye pain until I was doing a pupillary exam and noted that one pupil was fixed and dilated and she was screaming in intense pain when I shined a light in her eye).
 
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Not withholding any physical exam findings (interestingly enough, I did have my first acute angle closure glaucoma who actually presented as a headache, and did not specifically state it was truly eye pain until I was doing a pupillary exam and noted that one pupil was fixed and dilated and she was screaming in intense pain when I shined a light in her eye).

Sooo, what did you do? CTA, MRI, something very different?
 
As so many of you have stated, it was a very tricky clinical scenario. At my institution, we have a policy that the neurologist on call needs to be called immediately for all potential strokes. I called him up prior to the CT being completed, and discussed the case with him. I told him I was very concerned for a bleed. He's at the bedside by the time the patient is back from the scanner and is already asking the nurse to mix up the tPA and he was consenting the family. He had reviewed the images with the radiologist and stated that the patient had been effectively ruled out for SAH with negative CT at 1 hr after symptom onset. I told him I still was not comfortable with tPA, as simple ischemic strokes should not hurt, but he was adamant that no other other testing was necessary. The family was also pretty adamant about giving tPA after speaking with the neurologist. ICU was already down to see the patient and was putting in admit orders, as they frequently show up immediately for stroke alerts.

I decided to just walk away and document thoroughly as this was no longer my patient.

1hr later one of the nurses grabs me and tells me I'm needed in the patient's room because "she looks like ****". She is diaphoretic, BP 220/150, has right sided facial droop, is unresponsive and is vomiting. I intubated her, got fibrinogen levels, started her on cardene, and sent her back to CT which demonstrated something very similar to this:

6b27f219d46058dbf47f3c90d8f95f_gallery.jpg


I called the neurologist to let him know what happened and he went and talked to the family. She was given cryoprecipitate. MRI/MRA was later performed which did not actually demonstrate any aneurysmal bleed or dissection (so it is likely that CTA would not have changed management). They performed palliative extubation 5 days later and she died about an hour after extubation. The final diagnosis was ischemic stroke with hemorrhagic conversion, although I still don't believe this was a simple ischemic stroke given the presentation. Unfortunately not every case has a happy ending or feats of excellent doctoring.

My takeaways:
- Simple ischemic strokes should not hurt, look for alternative causes (dissection, SAH, etc)
- Try to be a better patient advocate when you believe a consultant might be too aggressive with their management, especially when you have time (although don't burn bridges)
- Sometimes, **** happens despite your best efforts to prevent it
 
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I figured this would be an interesting case to share to make others think about what they would do in this very sticky scenario.
 
I probably would have started with cta head and neck (includes non con), then TPA after discussion and consent with family

Good case
 
I figured this would be an interesting case to share to make others think about what they would do in this very sticky scenario.

Sounds like you took the best care of the patient that you could without the help of a crystal ball.
 
Nice work in a tough situation. Sounds like you didnt make any bad decisisons. Aside from possibly dealing with your consultant differently, is there anything you would have done differently? Seems like there is no other test that would have helped you
 
On rereading, I may have sounded harsh. I meant no offense, and was not throwing shade.

I think you were just playing the game.

In other words, "don't hate the player..."
 
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i disagree. ischemic strokes usually dont cause headaches. doesnt mean they never do.

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Ischemic strokes do cause pain (about 50% have a headache); however, it should not be a severe headache.

Always use your clinical judgement. Acute, sudden/intense onset headaches should have SAH strongly in the differential.

CT and CTA are NOT sufficient to rule out a sentinel bleed. According to our interventional neurologists and neuroradiologists, 8% of patients getting a CT angiogram with acute onset headache with a confirmed aneurysm will have it missed on the initial CTA due to vasospasm. This is why a CT followed by a lumbar puncture remains the gold standard of workup. Generally, those with positive xanthochromia, strong stories, or blood in their LP will have either a CTA done up to 3 times or angiography that is repeated in 3 weeks. Having said that, a non-contrast CT within 6 hours of onset approaches 100% sensitivity in picking up a SAH in the hands of good neuroradiologist.
 
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i disagree. ischemic strokes usually dont cause headaches. doesnt mean they never do.

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Having read through a review article on the incidence of headache in acute ischemic stroke, I'm unconvinced. Based on the article, ~30% of all ischemic stroke present with headaches. There is no comment on severity, however. Having done a month with the stroke team in medical school and the countless CVAs I've seen as a resident, I've never seen a single stroke present with a headache as chief complaint 1b that was not a bleed or dissection. Everyone has headaches. If you ask every single one of your patients in the ER if they've had a headache in the last day, half would probably say yes. I don't even mention a headache in the chart of most patients who mention they have a headache as a tertiary concern. My point was when the headache immediately coincides with neuro deficits and appears to be causing significant distress rather than being just an annoyance, I think you have to be very wary, because a simple ischemic stroke should not behave this way. Maybe I'm wrong and there is evidence out there to state otherwise, but I'll likely be much stronger in opposition to tPA the next time.
 
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Ischemic strokes do cause pain (about 50% have a headache); however, it should not be a severe headache.

Always use your clinical judgement. Acute, sudden/intense onset headaches should have SAH strongly in the differential.

CT and CTA are NOT sufficient to rule out a sentinel bleed. According to our interventional neurologists and neuroradiologists, 8% of patients getting a CT angiogram with acute onset headache with a confirmed aneurysm will have it missed on the initial CTA due to vasospasm. This is why a CT followed by a lumbar puncture remains the gold standard of workup. Generally, those with positive xanthochromia, strong stories, or blood in their LP will have either a CTA done up to 3 times or angiography that is repeated in 3 weeks. Having said that, a non-contrast CT within 6 hours of onset approaches 100% sensitivity in picking up a SAH in the hands of good neuroradiologist.

Where does this 8% number come from?
 
Case:

70+ yo F w/ hx of CVA 7yrs prior w/ residual mild expressive aphasia presents w/ severe expressive and receptive aphasia and severe headache. Onset 1hr prior to arrival, and the onset was actually witnessed by family member. The family member at bedside states she went from calmly eating her breakfast to placing her head in her hands in obvious, severe discomfort with an inability to communicate. The only thing the patient can clearly state without much provocation is that "it hurts" while pointing to her head. The patient has no history of headaches. She does have a hx of HTN and DM. She is not on any anticoagulation. She does take a baby aspirin daily, no plavix.

VS: HR-92, BP-155/100, RR-16, Temp-98.2 (Glucose: 105)

Physical exam
General: Alert but in moderate distress
HEENT: EOMI, PERRL, all otherwise unremarkable
CV: RRR, no murmur, 2+ pulses in all extremities
Resp: Unremarkable
GI: Unremarkable
Skin: unremarkable
Neuro: A&O to person only, unable to state current month or year, where she is at, or why she is here in hospital. Patient has difficulty following simple commands requiring multiple attempts before she is able to comprehend the command that is asked. She has significant difficulties communicating. No dysarthria. She has 3/5 strength in RLE and 4/5 strength in all other extremities. Patient does localize to pain b/l, but unable to communicate for accurate sensory exam.

Imaging
CT head: L sided old infarct, otherwise, no evidence of bleed or acute changes

What are you doing next?

To me this is an odd case. In today's day and age I always get a CTA in a significant stroke in an intervention window (we have IR capability), so that's the first thing. Second though, the neuro exam doesn't seem consistent with an ischemic stroke. History of mild aphasia now with aphasia, and bilateral weakness? NIHSS would get you enough for tpa but any time there's bilateral symptoms I look really hard for something else going on, because it's generally not an ischemic stroke.

That said, maybe one side of the weakness was old and the other side new, and it was an ischemic stroke that warranted tpa, and she bled. It happens sometimes.
 
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1hr later one of the nurses grabs me and tells me I'm needed in the patient's room because "she looks like ****". She is diaphoretic, BP 220/150, has right sided facial droop, is unresponsive and is vomiting. I intubated her, got fibrinogen levels, started her on cardene, and sent her back to CT which demonstrated something very similar to this:

6b27f219d46058dbf47f3c90d8f95f_gallery.jpg


I called the neurologist to let him know what happened and he went and talked to the family. She was given cryoprecipitate. MRI/MRA was later performed which did not actually demonstrate any aneurysmal bleed or dissection (so it is likely that CTA would not have changed management). They performed palliative extubation 5 days later and she died about an hour after extubation. The final diagnosis was ischemic stroke with hemorrhagic conversion, although I still don't believe this was a simple ischemic stroke given the presentation. Unfortunately not every case has a happy ending or feats of excellent doctoring.

My takeaways:
- Simple ischemic strokes should not hurt, look for alternative causes (dissection, SAH, etc)
- Try to be a better patient advocate when you believe a consultant might be too aggressive with their management, especially when you have time (although don't burn bridges)
- Sometimes, **** happens despite your best efforts to prevent it

Tough case. The rate of significant parenchyma hemorrhage after tPA is probably in the order of 3-5%. It may very well have been an ischemic stroke with hemorrhagic conversion and just crappy luck.
 
sudden onset headache and neurologic symptoms.......I would seriously consider LP before giving lytics.

If it is a burgeoning SAH, and you give the tpa........dead!

Strokes don't hurt.

You would feel comfortable pushing thrombolytics immediately after having performed a lumbar puncture? Although there's not much data to guide safety of lumbar puncture after thrombolytic administration, it seems like that would have a significant complication rate...
 
You would feel comfortable pushing thrombolytics immediately after having performed a lumbar puncture? Although there's not much data to guide safety of lumbar puncture after thrombolytic administration, it seems like that would have a significant complication rate...


I am never comfortable pushing thrombolytics......
 
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CT followed by CTA (if NIH > 6) and if NIH > 4 (obviously much greater in this case) informed consent by family for TPA after neuro blesses/concurs and all risks are explained to family. There's nothing else you can do. Everything else is mental masturbation. Ultimately, there's no way to tell which of these pt's are going to bleed on the rare event that it happens. I'm never the record setter in our ED for TPA administration because I take thorough time to explain the risks to the family with statistics, probability and best/worst case scenarios and have even used diagrams if I have to. You'd be surprised how many people will look at the numbers and say "Doc, can you give us a few minutes to discuss? I don't like those chances...even though they are relatively low..." I'm sure I have many more pt's refuse TPA after my "TPA talk" compared to others but what the hell. As much as I give it, I hate giving it. The best shops are going to be the ones where you have neurologists on site or over tele that can make the call for you. I'll be the first to admit that I start searching harder for reasons not to give it when the pt is over 65.
 
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If it's a legit stroke within window I usually tell my tech to do the ct without contrast and keep them on the table. Call me when done. They call, I look super quick for a bleed with them on the phone and the patient on the table. If no bleed--> cta. Adds about 4-5 minutes and you gain a ton of useful information including if this would be amendable to clot retrieval.
 
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If it's a legit stroke within window I usually tell my tech to do the ct without contrast and keep them on the table. Call me when done. They call, I look super quick for a bleed with them on the phone and the patient on the table. If no bleed--> cta. Adds about 4-5 minutes and you gain a ton of useful information including if this would be amendable to clot retrieval.


This is our "stroke protocol" now. Verbatim.
 
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