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How would you manage this stroke patient!

3K views 12 replies 4 participants last post by  DocSikorski 
#1 ·
A 22-year-old male abuser of intravenous heroin complained of severe headache while having sexual intercourse. Within a few minutes of that complaint, he developed right-sided weakness and became stuporous. His neurologic examination revealed neck stiffness, as well as right arm and face weakness. An unenhanced, emergency CT scan revealed a lesion of 3 to 4 cm in the cortex of the left parietal lobe. The addition of contrast enhancement revealed two other smaller lesions in the right frontal lobe but did not alter the appearance of the lesion in the left parietal lobe.

Within a day of admission, the right-sided weakness began to abate and within a week it completely resolved. On the fourth day of hospitalization, the patient abruptly lost consciousness and exhibited clonic movements starting on his right side and generalizing to his left side.

The movements stopped within 3 min, but he had residual right-sided weakness for 24 h. The CT scan was unchanged from that obtained on admission. The most appropriate treatment to institute involves

a. Heparin
b. Recombinant tissue plasminogen activator (r-TPA)
c. Urokinase
d. Phenytoin
e. Warfarin
 
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#2 ·
Thats a pretty much huge lesion...
Ok I have no clue.

For him to have embols in the head he should have ASD or VSD...
Talk from the heroin couldn't cause that damage either...
He is young and is sexually active... Might have AIDS
The contrast CT only showed those small lesions.

Man, I think its herpes...
Next time he sizes - I think he should be given phenytoin...

I go with D

homa_7 - note I said D (not c or z :)))
 
#10 ·
Seizures

This young man almost certainly has numerous problems associated with his intravenous drug abuse, but the cause of his current complaints is most likely bleeding from a mycotic aneurysm. Aneurysms are especially likely to bleed during exertion, such as that associated with sexual intercourse or defecation. That the lesion appeared largely the same on unenhanced and enhanced CT scans suggests that it is a hematoma.

Anticoagulation with warfarin or heparin and thrombolysis with r-TPA or urokinase are contraindicated in anyone with an intracranial hemorrhage. Focal seizures that secondarily generalize after an intracerebral or subarachnoid hemorrhage occur frequently and are appropriately treated with an antiepileptic drug, such as phenytoin (Dilantin).
 
#12 ·
This young man almost certainly has numerous problems associated with his intravenous drug abuse, but the cause of his current complaints is most likely bleeding from a mycotic aneurysm. Aneurysms are especially likely to bleed during exertion, such as that associated with sexual intercourse or defecation. That the lesion appeared largely the same on unenhanced and enhanced CT scans suggests that it is a hematoma.

Anticoagulation with warfarin or heparin and thrombolysis with r-TPA or urokinase are contraindicated in anyone with an intracranial hemorrhage. Focal seizures that secondarily generalize after an intracerebral or subarachnoid hemorrhage occur frequently and are appropriately treated with an antiepileptic drug, such as phenytoin (Dilantin).
Had he been bleeding it would be seen in the CT scan , you said non enhanced Ct scan shows a lesion ( could be bleeding or tumour or aneurysms ) but to see more on a enhanced one rules out bleeding ...... or hematomas which are clearly seen on non enhanced one ....

anyways Give A Cigar to Docsikorski .... :)) ......great diagnosis Sir ........:D
 
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