Clinical Reasoning: Mechanical thrombectomy for acute ischemic stroke in the setting of atrial myxoma

Contents

Summary

  • 23yo F
  • c/c
    • emergency dep
    • 2h Hx of
      • hemiplegia
        • acute onset
        • Rt-sided
      • aphasia
  • PMH
    • migraine
    • tabacco use

Further

Terminology

Original

Section 1

A 23-year-old woman with a medical history of migraines and tobacco use was brought to the emergency department with a 2-hour history of acute onset, right-sided hemiplegia and expressive aphasia. The patient had never experienced similar symptoms in the past. Her migraines occurred 3 times weekly, lasted 1–2 days, and were characterized by photophobia along with bilateral headache of a right-sided predominance. She took acetaminophen and ibuprofen for pain relief. Her family history was significant for a sister with glucose-6-phosphate dehydrogenase deficiency.

The patient was afebrile on admission with a blood pressure of 112/62 mm Hg and regular heart rate of 64. General physical examination was within normal limits. Upon neurologic examination, she was awake, alert, tracking, able to follow all commands, but displayed expressive aphasia. Cranial nerves testing was significant only for right homonymous hemianopsia and right facial droop consistent with upper motor neuron facial weakness. Motor examination revealed flaccid right-sided hemiplegia. Loss of sensation to light touch was noted on the right. The patient was given an NIH Stroke Scale (NIHSS) score of 19. Identified stroke risk factors included smoking, obesity, and oral contraceptive use.

Questions for consideration:

  1. What is the differential diagnosis for the right-sided hemiplegia and expressive aphasia?
  2. Is the patient’s presentation explained by her migraine history?

Section 2

The differential diagnosis for acute onset, right-sided hemi- plegia and expressive aphasia includes stroke, seizure, de- myelinating disease, metabolic encephalopathy, complicated migraine, or functional neurologic dysfunction (e.g., conver- sion disorder). The patient’s presentation was unlike her usual migraines as she did not complain of bilateral headache/ photophobia and had new right-sided motor weakness. Due to acute onset of symptoms and objective findings on neu- rologic examination, the most likely diagnosis was thought to be stroke. The clinical syndrome was localized to the con- tralateral middle cerebral artery (MCA) territory. Her head CT scan was negative for acute blood, but was found to have an ASPECTS score of 7/10 (figure, A) due to hypodense left caudate, lentiform, and insular regions, raising suspicion for an acute left MCA infarct. Given the absence of hemorrhage on head CT and concern for ischemic stroke, the patient received IV thrombolytic therapy (tPA) which, when given within 4.5 hours of symptom onset, has been shown to improve chances of a good functional outcome by establishing reperfusion.[1]