DOUBLE JEOPARDY

1. DOUBLE
JEOPARDY
Dr Manikandan R
DNB Post Graduate
SUNDARAM ARULRHAJ HOSPITALS

2. History
 55 yr old Diabetic and Hypertensive Female
admitted in ER with c/o Weakness in left UL &
LL since today morning 3 am
 H/o Palpitations associated with sweating
 No H/o Chest pain
 No H/o LOC /Vomiting/Seizures.

3. General Examination
 Conscious,Oriented and Afebrile.
 PR-82/min,BP-110/70.
 RS-BAE+
 CVS-S1S2+
 P/A-Soft,nontender
 CNS-Respond well to verbal commands, EOM +, PERL+,
Fundus-Disc Clear, No neck Rigidity
 Rt Lt
 Tone N Hypotonic
 Reflex Not Elicitable Not Elicitable
 Plantar Normal Extensor
 Power UL 4/5,LL 4/5 UL 3/5 LL 2/5

4. Clinical Diagnosis
 ACUTE CEREBROVASCULAR DISEASE-
 ? ISCHEMIC/HEMORRHAGIC INVOLVING
RIGHT MIDDLE CEREBRAL ARTERY
TERRITORY- Left Hemiparesis.

5. Investigations
 Sugar-212, Urea-48,Creat-1.4, Hb A1C-
7.9
 BT/CT-3/6 min,Platelet-3.3 lakhs
 TC-216,TGL-178,LDL-135
 ECG-ST Elevations in V4,V5 and
 Q waves in V2,V3
 Trop I -4.65(Positive),CKMB-
19.08(Positive)
 Echo- EF-40,CAD involving IVS & AW
 Electrolytes- 136/4.6/104/20
 CT Brain- Old lacunar infarct.No
ICH,Calcified Granuloma in left frontal
and Parietal lobe.

6. Course in the hospital
 Immediately shifted to CATH LAB For
Angio- Proximal LAD-95% & Mid LAD
90% Lesion Bare Metal Double Stenting
done
 Eptifibate,Low molecular weight heparin
and Antiplatelets given.
 Strict Diabetic & Hypertension control
 F/U CT Brain-Tentorial Bleed,Acute
infarct in Rt Parietal lobe(ACA), Calcified
Granuloma in left Parietal lobe
 Fresh Frozen Plasma given
 Nimodipine (preventing vasospasm)
 LMW Heparin low dose started by
Checking APTT(T-41,C-29)
 Other Antiplatelets(Ecosprin and Plavix)
Stopped.
 Strocit and Eptoin started.

7. Final Diagnosis
 ACUTE ISCHEMIC STROKE – RIGHT MIDDLE CEREBRAL
ARTERY TERRITORY WITH LEFT HEMIPARESIS
 ACS- ANTERIOR WALL M I- LAD Double Stenting Done.
 TENTORIAL BLEED
Current Clinical Issue-Post PCI Anticoagulants Antiplatelets
Induced Tentorial Hemorrhage
 Comorbids
UREAMIA/DYSLIPIDEMIA
T2DM/HTN
POOR LV

8. Acute Phase Management
 Anticoagulant Reversal should be the primary
Consideration in the first 24 hours.
 Lines of Reversal
Fresh Frozen Plasma & Fresh Blood
Prothrombin Complex Concentrates
Recombinant Factor 7a
Vitamin K

9. Follow up CT Brain
 Resolving Tentorial bleed.
Subacute infarct in Rt
Parietal region. Calcified
granulomas in Lt parietal
lobe.

10. Discussion:Risk Factors for ICH
during Anticoagulant therapy
 Advancing
age(>75yrs)
 HTN(SBP>160)
 h/o Cerebrovascular
Disease
 Intensity of
anticoagulation
 Concomitant use of aspirin
 Cerebral amyloid
angiopathy
 Tobacco smoking
 Heavy alcohol
consumption
 Microbleeds by T2
weighted MRI
 Asian or Mexican-
American ethnic.
Firmly Established Possible Risk factors

12. How to avoid…
 Blood Pressure Control
 Diabetic Control
 Good control of Heparin/Warfarin intensity by
Regularly checking APTT/PT-INR
 Limiting the use of Aspirin

13. Further Comes….
 Patient Clinically Improved
 Managed on Antiplatelets
 Discharged

14. Why this case is Presented?
 Right MCA Territory Ischemic Infarct
 CAD- Proximal and Mid LAD 90% Lesion
 PCI Done
 POST PCI Bleed
 Successfully Managed…

15. THANK
YOU