Explain this CVA to me please..

[FiremedicMike]

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Not sure if this is the right forum for this question or not, but here goes.

We are dispatched on an unconscious person, arrive to find a very conscious and scared ~70 yo female at the buffet, noted no slurred speech. She has not eaten yet and is complaining of left arm numbness. I attempt to do a quick check for pronator drift, patient is able to hold right arm up, left arm drops immediately but does not pronate, this was with eyes open, no grip strength on left side at all.. I check her sugar in the restaurant and get 167mg/dL, IIRC vitals are somewhere around 170/100, HR 90.

Transfer her to the truck, EKG is normal sinus with no changes. I now check for facial droop, on grimace patient is able to pull left side back fine but almost seems that she's purposely not allowing her right side to come back. As a reminder, the numbness is in her left arm. For some reason I decide to check the strength in her feet. She is able to push her toes down on her left foot, but not her right, I did not ask her to pull her toes back up, again, this is her right foot giving her problems as opposed to the numbness in her left arm. Throughout transport I am definitely noticing purposeful movement in her left arm, however she continues to ask "where is my arm" and adamantly insists that her left arm is completely numb up to her shoulder.

So I've never seen anyone fake a stroke before, but these symptoms were too weird for me. I advised my findings via radio, stroke team was not activated so apparently at least based on my radio report they agree.

Fast forward 2-3 hours and we're back at the ER again. I check in with the family who says "yep she had a stroke". I check with the nurse who said no bleed, did have a stroke though, is receiving TPA and headed upstairs. Sadly none of the docs were too familiar to me, and the ED was extremely busy, so I didn't ask any of them to explain.

So here I am, explain. I've never seen a stroke effect some things on left and other things on right. What is going on with this patient if you are familiar with similar cases..

 

[Flopotomist]

Not sure if this is the right forum for this question or not, but here goes.

We are dispatched on an unconscious person, arrive to find a very conscious and scared ~70 yo female at the buffet, noted no slurred speech. She has not eaten yet and is complaining of left arm numbness. I attempt to do a quick check for pronator drift, patient is able to hold right arm up, left arm drops immediately but does not pronate, this was with eyes open, no grip strength on left side at all.. I check her sugar in the restaurant and get 167mg/dL, IIRC vitals are somewhere around 170/100, HR 90.

Transfer her to the truck, EKG is normal sinus with no changes. I now check for facial droop, on grimace patient is able to pull left side back fine but almost seems that she's purposely not allowing her right side to come back. As a reminder, the numbness is in her left arm. For some reason I decide to check the strength in her feet. She is able to push her toes down on her left foot, but not her right, I did not ask her to pull her toes back up, again, this is her right foot giving her problems as opposed to the numbness in her left arm. Throughout transport I am definitely noticing purposeful movement in her left arm, however she continues to ask "where is my arm" and adamantly insists that her left arm is completely numb up to her shoulder.

So I've never seen anyone fake a stroke before, but these symptoms were too weird for me. I advised my findings via radio, stroke team was not activated so apparently at least based on my radio report they agree.

Fast forward 2-3 hours and we're back at the ER again. I check in with the family who says "yep she had a stroke". I check with the nurse who said no bleed, did have a stroke though, is receiving TPA and headed upstairs. Sadly none of the docs were too familiar to me, and the ED was extremely busy, so I didn't ask any of them to explain.

So here I am, explain. I've never seen a stroke effect some things on left and other things on right. What is going on with this patient if you are familiar with similar cases..

I wonder what her baseline is. Is it possible that some of her findings were old, and that she indeed had new findings on the contralateral side? Did she have any history of something bizarre (eg factor V leiden or something)?

 

[FiremedicMike]

I wonder what her baseline is. Is it possible that some of her findings were old, and that she indeed had new findings on the contralateral side? Did she have any history of something bizarre (eg factor V leiden or something)?

Not sure what factor V leiden is, but I can tell you no previous CVA/TIA history. I don't honestly remember if I specifically asked her if any of her symptoms were old, but she seemed to give me the impression they were new.

 

[jimminycricket]

Not sure what factor V leiden is, but I can tell you no previous CVA/TIA history. I don't honestly remember if I specifically asked her if any of her symptoms were old, but she seemed to give me the impression they were new.

did she seem histrionic? was there a domestic dispute? conversion disorder moves up on my list..

 

[Arcan57]

I favor the right being an old deficit. Asomatognosia could account for her not knowing where her left arm is, and that can definitely fall under the realm of stroke. She may have motor function but not conscious control of the limb.

The old stuff can make diagnosing a stroke difficult, I had known quadriplegic patient who presented as unresponsive, ended up having thrombosed their basilar artery and being locked-in.

 

[gutonc]

Not sure what factor V leiden is, but I can tell you no previous CVA/TIA history. I don't honestly remember if I specifically asked her if any of her symptoms were old, but she seemed to give me the impression they were new.

It's a mutation in the Factor V clotting protein that can predispose to VTE (but not arterial embolic event). But I have no idea why Flopotomist brought it up in this case.

 

[Apollyon]

Patient needs an echocardiogram. I had a similar patient a few years ago. The neurologist thought she was faking (because the exam was so inconsistent). I talked about it with a friend of mine who is neurorads. She said it's likely one of two things: either faking, or septic emboli. Turns out this lady had an aortic valve covered in a lactobacillus you find in the soil (not yogurt). It was shooting out tiny emboli like a Roman candle. She died while ID and CT surgery were hashing it out (ID wanted to get the right antibiotics on her before surgery, but CT just wanted to get that valve out of there ASAP).

 

[WilcoWorld]

Factor V was brought up for the same reason as septic emboli - it could be multiple areas of infarction, which Factor V Leiden would predispose one to.

Posterior CVA's / brainstem infarctions can produce crossed symptoms as well.

Multiple Sclerosis could produce this exam, but the onset wouldn't be so acute.

If the patient was a 24 year old with an odd neuro exam I'd be much more inclined to call shenanigans. In a 70 year old malingering seems less likely then true CVA (given the difference in pre-test probabilities). In any case, I hope the doc had a decent hypothesis to explain the odd exam findings before he or she pushed tPA.

 

[leviathan]

Factor V was brought up for the same reason as septic emboli - it could be multiple areas of infarction, which Factor V Leiden would predispose one to.

Posterior CVA's / brainstem infarctions can produce crossed symptoms as well.

Septic emboli seems like a good explanation if she had multiple/simultaneous clots showering off. Or could afib do this as well? Besides septic emboli what about marantic endocarditis, SLE / antiphospholipid syndrome, or one of the vasculitides? There's probably lots of other zebras I'm forgetting here...lol.

Some brainstem infarcts can produce ipsilateral facial deficits with contralateral deficits to the body (PICA, AICA infarcts), but are there any that affect upper vs. lower limbs contralaterally?

 

[Flopotomist]

It's a mutation in the Factor V clotting protein that can predispose to VTE (but not arterial embolic event). But I have no idea why Flopotomist brought it up in this case.

I brought it up because I didn't know (until I just went back and reviewed) that Factor V Leiden led more to venous thromboses as opposed to arterial ones - I have only seen one case of it, and the one case I saw involved a guy with multiple CVAs. I now know that his presentation was atypical, so my n of 1 has led me to chase the wrong zebra here.

I would say though that in a 70 year old with these symptoms, I would not jump on the conversion disorder bandwagon.

 

[Siggy]

It was shooting out tiny emboli like a Roman candle. She died while ID and CT surgery were hashing it out (ID wanted to get the right antibiotics on her before surgery, but CT just wanted to get that valve out of there ASAP).

If you could, is there any chance you could describe this conflict a little more. As a naive soon to be OMS-2, what benefit would there be in waiting for antibiotics before surgery?

 

[Apollyon]

If you could, is there any chance you could describe this conflict a little more. As a naive soon to be OMS-2, what benefit would there be in waiting for antibiotics before surgery?

I heard about it ex post facto, when I ran into the neurologist again, so the horse was already out of the barn. The entire story is that ID figured all the manipulation would send bacteria everywhere.

 

[gutonc]

She died while ID and CT surgery were hashing it out (ID wanted to get the right antibiotics on her before surgery, but CT just wanted to get that valve out of there ASAP).

Two things I've been thinking about re: this case (knowing only what you stated above):

1. The outcome probably would have been the same, regardless of who "won" that fight.

2. I've never seen a situation where surgery (any sub-specialty, except for vascular...those yahoos will operate on anything) wanted to rush an acutely infected patient to the OR without at least one dose (or one day or one week or...) of bug juice on board. Which is probably because they are thinking about item 1 above and would rather the inevitable death not go on their stats.

 

[Apollyon]

Two things I've been thinking about re: this case (knowing only what you stated above):

1. The outcome probably would have been the same, regardless of who "won" that fight.

2. I've never seen a situation where surgery (any sub-specialty, except for vascular...those yahoos will operate on anything) wanted to rush an acutely infected patient to the OR without at least one dose (or one day or one week or...) of bug juice on board. Which is probably because they are thinking about item 1 above and would rather the inevitable death not go on their stats.

I'm sorry I don't have more to offer, because I've given you all I got about it. I just remember it was a soil bug because she worked with developmentally disabled kids, and I was thinking about pica and eating dirt.

 

[loveboatdoc]

I know of a 75 y/o f with both factor 2 and 5 deficiency. She has had 3 strokes. Her 50ish daughter also inherited this rare combo, and they are enrolled in a UCLA study. I was told only 200 pts have been found so far for this study, since it's such a rare bird. The daughter has a "string-of-pearls" series of clots in her leg, with frequent pain and swelling. They take Levonox before flying (actually the daughter cannot even fly), are both waaay obese, and seem like walking time bombs.

The inheritance rate is 50% for this.