Paresthesias and clinical case

[migm]

Clinical case, curious what you would do. You're at a single coverage ED about 1 hr away from civilization by ground, you have access to CT, that's it at night. Admission for speciality care occurs at the main hospital and the wait for a bed can be anywhere from 4-24 hours depending.

48yom, HTN, +smoking, +fhx MS presents with ~12hrs of acute onset of L face and L arm paresthesias, states "right below my eyeball" then down on one side of face only, involving tongue (feels heavy) and entirety of L arm. No prior hx of similar, no headache, no other neuro sx. VS show bp 194/104 rest of vs are normal. Labs normal, HCT, CXR and EKG are wnl.

Additional eval? Discharge? Txfer for further care? No MRI in house.

Curious how others manage paresthesia only patients

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[gro2001]

To be clear: absolutely no neuro deficit? No weakness? Gait is normal? No visual field defects? No sensory defects over the area of the paresthesias? Also, how did the patient describe his symptoms? Was it 'pins and needles'? Or 'my arm fell asleep' kind of paresthesias? And how strong is this family history? Did he have any personal history of weird episodes with his vision at any point in his life?

I think I would treat as a 12 hour old stroke, even if it's not necessarily what this is. Does your hospital have a protocol on what to do with acute strokes outside the tPA window? Do you have a neuro consult you can call? If not, I would get FS, labs, CXR, ECG, CTH, and transfer. I don't think I'd send this patient home.

 

[BAM!]

I agree. Either consider TIA or CVA. In my experience, MS is usually a little more scattered-non-stroke-like symptoms. And 48 yo is a little late for initial symptoms.

Head CT -- maybe you'll see something. unlikely though. Gotta get it before you give ASA.
He's not a TPA candidate because of time-frame, so that part is easy. Did you get a pysch/social vibe from him? Is he freaking out about his blood pressure? Maybe a little labetalol and see if he feels better. If that works, then you call it a TIA, ABCD2 score is 3 and he goes home with outpatient follow up. Give him ASA or maybe some sort of anti-platelet agent / aggrenox or such. That said, my hospital has good follow up. Not sure what your situation is like.

Do you have Neuro on call? Call them and see if they want admission vs discharge. If your hospital doesn't have a Neurologist or MRI, they should be transferred somewhere that does.

Anyway you cut it, stroke with paresthesias only is pretty weak, but this I think could be an easy sell to a transfer-accepting internist.

 

[Apollyon]

Out in the middle of nowhere, you don't have neuro. Where I work (in the middle of the forest), my "neuro" is two hours away by ground. They'll take any transfer, and will always talk to you, but no live bodies anywhere.

Of course, someone will say "but I do!". You're the exception.

 

[Janders]

This a tiny infarct on MRI until proven otherwise (at least the last couple I've had were...)

So what you do depends on local custom. Xfer for Neuro. TeleNeuro. Admit to hospitalist who is comfortable with simple neuro. Discharge to urgent neuro followup clinical.

 

[migm]

To be clear: absolutely no neuro deficit? No weakness? Gait is normal? No visual field defects? No sensory defects over the area of the paresthesias? Also, how did the patient describe his symptoms? Was it 'pins and needles'? Or 'my arm fell asleep' kind of paresthesias? And how strong is this family history? Did he have any personal history of weird episodes with his vision at any point in his life?

I think I would treat as a 12 hour old stroke, even if it's not necessarily what this is. Does your hospital have a protocol on what to do with acute strokes outside the tPA window? Do you have a neuro consult you can call? If not, I would get FS, labs, CXR, ECG, CTH, and transfer. I don't think I'd send this patient home.

He says it feels different than the other side when you touch the affected areas. States there is decreased sensation to light touch. A wooden sensation. Fhx was his father. And no regarding vision.

I agree. Either consider TIA or CVA. In my experience, MS is usually a little more scattered-non-stroke-like symptoms. And 48 yo is a little late for initial symptoms.

Head CT -- maybe you'll see something. unlikely though. Gotta get it before you give ASA.
He's not a TPA candidate because of time-frame, so that part is easy. Did you get a pysch/social vibe from him? Is he freaking out about his blood pressure? Maybe a little labetalol and see if he feels better. If that works, then you call it a TIA, ABCD2 score is 3 and he goes home with outpatient follow up. Give him ASA or maybe some sort of anti-platelet agent / aggrenox or such. That said, my hospital has good follow up. Not sure what your situation is like.

Do you have Neuro on call? Call them and see if they want admission vs discharge. If your hospital doesn't have a Neurologist or MRI, they should be transferred somewhere that does.

Anyway you cut it, stroke with paresthesias only is pretty weak, but this I think could be an easy sell to a transfer-accepting internist.

\\

No psych vibe on him.


I did transfer him, and he did have a tiny thalamic stroke, but I can so see sending these people home. Like, what if his BP was just a little high, or what if he did give me a psych vibe. Seems a bit arbitrary, but also seems like MRI all paresthesias is crazy too.

 

[WilcoWorld]

He says it feels different than the other side when you touch the affected areas. States there is decreased sensation to light touch. A wooden sensation. Fhx was his father. And no regarding vision.

\\

No psych vibe on him.


I did transfer him, and he did have a tiny thalamic stroke, but I can so see sending these people home. Like, what if his BP was just a little high, or what if he did give me a psych vibe. Seems a bit arbitrary, but also seems like MRI all paresthesias is crazy too.

I'll discharge isolated limb paresthesias that are otherwise well. But a hypertensive smoker with tongue involvement is a stroke until proven otherwise.

Without the MS history, admitting locally for stroke work up/risk modification is reasonable, as there's nothing urgent to do with 12 hours of symptoms. Add in the MS and I doubt most hospitalists would be comfortable admitting - I wouldn't fault them for that.

This raises the question of how much benefit you get from admitting a completed stroke, but that's a whole other conversation - one I'd be more interested in having after I move to Texas.

 

[GonnaBeADoc2222]

When I first read the above description, I thought it sounded like cheiro-oral syndrome, which after you saying the patient had a small thalamic infarct it would appear to be the case.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532880/

How the heck did I associate it with this? The only reason is because we've had a couple of cases at my shop in the past couple of years - one that ended up as an M&M. Weird, huh?

 

[WilcoWorld]

I should perhaps clarify that the most salient feature of the case was the tongue involvement - that is the red flag much more than the BP or smoking history. I'll discharge smoking hypertensives with extremity tingling unless there's something else worrisome. But peripheral neuropathies aren't going to involve arm and tongue, so it's the tongue symptoms earn you a work up.

 

[migm]

I should perhaps clarify that the most salient feature of the case was the tongue involvement - that is the red flag much more than the BP or smoking history. I'll discharge smoking hypertensives with extremity tingling unless there's something else worrisome. But peripheral neuropathies aren't going to involve arm and tongue, so it's the tongue symptoms earn you a work up.

What if it was face and arm only? Could still be thalamic or parietal

 

[txterp98]

To quickly summarize: you're at a critical access hospital with a patient describing ongoing sensory deficits (that don't fit a pattern of peripheral neuropathy) that are still present. Your non-contrast CT Head is negative.

Transfer for Admit. On to the next one.

The receiving hospital's practice standards determine whether they get a formal Neuro consult or if IM manages exclusively on their own (likely with an MRI/MRA).

I hope you guys never have Teleneurology. From setup to consult completion to receiving the faxed recommendation of "transfer for MRI" will add 2.5 hours to their length of stay.

To be honest, the question is a lot trickier if you had put the patient in the TPA window. (I wouldn't give TPA for this patient but I'd say the case has more medicolegal liability associated with it.)

 

[WilcoWorld]

What if it was face and arm only? Could still be thalamic or parietal

You're correct, and in that case it would depend on the rest of the details. I'm not saying face+arm = not CVA. But if you add in the tongue you've definitely got my attention.

 

[migm]

I have seen some individuals blow off paresthesia only in the past and so I was just checking that I'm not being the overly-conservative junior attending that residency wants me to be.

Also, tele-neuro for us takes about 15 minutes to setup, and you get a phone call with the results, turnaround is way, way.. way way faster than a neuro consult in residency (uh yeah we gotta round with our attending at 7am, can you keep them in the ER until then and get 19,000 tests? k thanks)

 

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[gamerEMdoc]

Sounds like a classic pure sensory lacunar infarct. I'd admit/transfer for the usual stroke risk factor workup that every TIA/new stroke gets.

 

[n2b8me]

OK. I'll play. I would do CT angiogram of neck and circle of willis. If this was positive for a clot then you have a diagnosis, but if normal then I would call Neurology on call for advice recommendations (usually they want to admit for an MRI since it is not available at night). If you don't have a neurologist I would call and admitting doc to have them admit. If you have NO MRI EVER... that's trickier I think I would talk to the patient about transferring or having further outpatient workup and stop smoking, control bp, take statin and antiplatelet. I would also give him something for his BP - hydralazine. This is (probably a lacunar infarct that will not evolve and he is good for outpatient mgmt in my eyes.

 

[BAM!]

I hope you guys never have Teleneurology. From setup to consult completion to receiving the faxed recommendation of "transfer for MRI" will add 2.5 hours to their length of stay.

Not our shop. Teleneuro is super fast. Cases generally done within an hour from hitting the door. Keep in mind, Teleneuro is generally only for TPA candidates (at least in my experience).

 

[gro2001]

Out in the middle of nowhere, you don't have neuro. Where I work (in the middle of the forest), my "neuro" is two hours away by ground. They'll take any transfer, and will always talk to you, but no live bodies anywhere.

Of course, someone will say "but I do!". You're the exception.

What I meant (and maybe I wasn't clear in my post) was that if there is a neurologist by phone or tele-neurologist available, I would call and discuss with them. If not, then I would transfer to the nearest place with a neurologist (even if it's 2 hours away) for a consultation and anticipated admission for what I am considering an acute stroke outside the interventional window.

I realize that most places, particularly those "in the middle of nowhere" won't have an in house neurologist. However, many of those places will have some system for you to speak to a neurologist, whether it is by phone or via one of those fancy tele-medicine robo doc set ups.

 

[gro2001]

He says it feels different than the other side when you touch the affected areas. States there is decreased sensation to light touch. A wooden sensation. Fhx was his father. And no regarding vision.

\\

No psych vibe on him.


I did transfer him, and he did have a tiny thalamic stroke, but I can so see sending these people home. Like, what if his BP was just a little high, or what if he did give me a psych vibe. Seems a bit arbitrary, but also seems like MRI all paresthesias is crazy too.

Decreased sensation to light touch is more worrisome than paresthesias. In that case, I would definitely not send him home.

 

[Birdstrike]

Clinical case, curious what you would do. You're at a single coverage ED about 1 hr away from civilization by ground, you have access to CT, that's it at night. Admission for speciality care occurs at the main hospital and the wait for a bed can be anywhere from 4-24 hours depending.

48yom, HTN, +smoking, +fhx MS presents with ~12hrs of acute onset of L face and L arm paresthesias, states "right below my eyeball" then down on one side of face only, involving tongue (feels heavy) and entirety of L arm. No prior hx of similar, no headache, no other neuro sx. VS show bp 194/104 rest of vs are normal. Labs normal, HCT, CXR and EKG are wnl.

Additional eval? Discharge? Txfer for further care? No MRI in house.

Curious how others manage paresthesia only patients

There's more to be lost (by you and the patient) by calling this a benign paraesthesia and it turning out to be a CVA, than calling it a presumed CVA and it turning out to be a benign paraesthesia. Admit.

You must think this way when you have on your differential diagnoses that are life or limb threatening, that you don't have a quick rule-out test for, that has a high negative predictive value (likelihood of a normal test, making you certain the patient is normal). CVA and ACS are the biggest that come to mind.