Clinical Lecture Demonstration - Stroke and AF Summary 74 years old known patient with hyperthyroidism, DM, HTN, DL, Paroxysmal AF & Thyrotoxic cardiomyopathy Presenting with right sided arm, leg weakness for two hours duration. No loss of consciousness preceding headaches fits or double vision. patient is a passive smoker. No other risk factors present. HTN is well controlled. On Examination Right sided UMN type Facial nerve palsy with dysarthria and Power, Tone, Reflexes are diminished on Right Upper and Lower limbs by, Pamudith Karunaratne Heshani Karunanayake Monali Kalupahana

1. Clinical
Lecture
Demonstration
Monali Kalupahana
Heshani Karunanayake
Pamudith Karunaratne

2. Introduction
● Name: Mrs. xxxx xxxx
● Age: 74 Years
● Gender: Female
● Address: xxxxxx
● DOA: 17th June 2021
● Known
patient
with:
Hyperthyroidism,
DM, HTN, DL

3. Presented with
Right Sided
Arm & Leg Weakness
for 2 hrs

4. History of
Presenting Complaint
Patient developed sudden onset right sided upper limb
and lower limb weakness and slurring of speech while
taking a bath
UL=LL
With time the weakness progressively increased
Slurring of speech (dysarthria) with mouth deviation to
left side
No Loss of consciousness, preceding headaches, double
vision, giddiness or vomiting
Brought to the hospital within 2 hrs

5. ● No missed meals, no autonomic symptoms Hypoglycaemia
● no fever ,neck stiffness ,photophobia ,altered
behaviour
CNS infection
● no chronic headache, features of raised
intracranial pressure
SOL – Cerebral tumour,
cerebral Abscess
● No fits ,postictal drowsiness, past history of
seizures
Seizure
● no history of aura, precipitating factors ,past
history of migraine
hemiplegic migraine
 Systemic inquiry was unremarkable

6. Risk Factors
 Disease related
 Thyrotoxic cardiomyopathy
 Arrythmia (Paroxysmal AF)  Not on Warfarin
 DM
 DL 8 years
 HTN
 No IHD, Valvular heart diseases, bleeding disorders,
polycythaemia
 Lifestyle
 passive smoker
 physical inactivity

7.  Hyperthyroidism  16 Years ago
 FNAC – Autoimmune thyroiditis
 anti thyroid drugs given
 radio Iodine – done
 Cardiac myopathy
 currently on thyroxine
 diabetes mellitus  8 Years ago
 currently on clinic follow up
 oral hypoglycaemic drugs
 Microvascular – retinopathyo/ neuropathy+/ nephropathy+
 Macrovascular – PVDo / strokeo / IHDo
 No autonomic neuropathy
 Hypertension
 Dislipidaemia
 8 Years – on clinic follow up
Past medical history

8. Drug History
 Gliclazide 80 mg bd
 Spironolactone 25 mg m
 Prazosin 2.5 mg bd
 O Carvedilol 3.125 g bd
 Atorvastatin 40 mg n
 Captopril 50 mg tds
 Ecosprin 75 mg n
 Thyroxine 75 mg m

9.  PSHx  Nil
 Family Hx  No Strokes, Thyroid Diseases,
DM, HTN, Autoimmune, Renal
diseases
 Allergy Hx  Fo / Do / Po
 Social Hx  widow
 educated up to grade 9
 Lives with two sons and their
families  Good family support
 one storied house
 has an attached bathroom with
squatting toilet
 financially stable
 nearest hospital – xxxx – 15
minutes by own three-wheeler

10. Stroke or TIA
Hypoglycemia
CNS Infection
SOL
Seizure
Hemiplegic
Migraine
Differential diagnosis

11. Physical Examination
 Averagely built lady, lying supine on the bed.
 Conscious & Alert, GCS 15/15
 Green cannula on the left hand
 Afebrile , Not pale or plethoric
 No Xanthelasma, Corneal arcus
 No hair loss, Skin turgor normal
 No central cyanosis
 Oral hygiene good, no dental caries, No gum
bleeding
 No Ear discharges, no neck stiffness
 No visible neck lumps
 No clubbing, No peripheral stigmata of IE
 No Ankle oedema
 No foot ulcers

12. Physical Examination
CVS
 PR – 60 bpm, Regular, Normal Volume
 All peripheral pulses felt
 BP 125/75 mmHg
 CRFT < 2sec
 Apex – 6th Intercostal Space, Anterior Axillary line, Normal Character
 Auscultation
 S1, S2 Heard
 No S3 (Gallop rhythm)
 No murmurs
 No carotid bruit

13. Physical Examination
RS
 RR 14 breaths per min
 Vesicular breathing
 B/L air entry was equal
 Clear lungs
 No bi-basal end inspiratory crepitations
 No other added sounds

14. Physical Examination
Abdominal
 Abdomen soft
 Not distended
 Non tender
 No hepatosplenomegaly
 Bowel sounds present

15. Physical Examination
CNS
 Well oriented
 Higher functions are intact
 Right sided UMN type Facial nerve palsy with dysarthria
 Motor System
 On admission right upper and lower limbs -Tone reduced,
Power 4/5, Reflexes diminished, Right side plantar upgoing
 Sensory System
 In all limbs  Touch, Pain, Vibration & Proprioception are intact
 Cerebellar signs intact

16. Summary
74 years old known patient with
hyperthyroidism, DM, HTN, DL,
Paroxysmal AF & Thyrotoxic
cardiomyopathy Presenting with
right sided arm, leg weakness for
two hours duration. No loss of
consciousness preceding
headaches fits or double vision.
patient is a passive smoker. No
other risk factors present. HTN is
well controlled. On Examination
Right sided UMN type Facial nerve
palsy with dysarthria and Power,
Tone, Reflexes are diminished on
Right Upper and Lower limbs

17. Problem List?

18. Problem List
 Right Sided Hemiplegia
 Slurring of Speech
Acute
Medical
 Thyrotoxic
cardiomyopathy
 Diabetes mellitus
 Hypertension
 Dyslipidaemia
 Hypothyroidism
 Atrial fibrillation
Chronic
Medical
 Passive smoker
 Squating toilet at home
Social

19. What is the
lesion
and
where is the
lesion?

20. Acute Management at ETU

21. NCCT - Brain
No Haemorrhagic
manifestations.

22. Acute Management at ETU

23. AHA/ASA
Stroke guidelines
(Stroke. 2019;50:e344–e418.
DOI: 10.1161/STR.0000000000000211.)

24. AHA/ASA
Stroke guidelines
(Stroke. 2019;50:e344–e418.
DOI: 10.1161/STR.0000000000000211.)

25. NIHSS

26. NIHSS
NIHSS = 6/42  Moderate Stroke

27. rtPA Exclusion Inclusion criteria

28. rtPA Exclusion Inclusion criteria
CCP Stroke guidelines 2017

29. Investigations
Summary

30. ECG
Sinus Bradycardia with no ongoing AF

31. Investigations Summary
112 mg/dl
FBS
pH 7.45
pCO2 37.1 mmHg
HCO3- 26 mmHg
VBG
WBC 9.50 x 109 (4-10)
N 69%
L 25%
Hb 13 g/dl
RBC 5 x 106 /L (4.5-5.5)
PLT 198 x 109 (150-450)
FBC 2.5 μIU/L (0.5-8.9)
TSH
AST 23.1 IU/l (<50)
ALT 16.5 IU/l (<50)
Urea 4.8 mmol/l (2.8-7.2)
S. Cr. 83.7 mmol/l (74-100)
Na+ 138 mmol/l (136-146)
K+ 4.9 mmol/l (3.5-5.1)
CRP 6.1 mg/dl (<5)
LFT
EF = 30%
Thyrotoxic Cardiomyopathy
2D Echo

32. Carotid Artery Duplex Scan

33. Management in the ward

34. Discharge Plan

36. Risk
Similar magnitude for other
vascular events such as
myocardial infarction
Risk of developing another stroke
5%  within the first week
26%  within 5 years
after an acute stroke

37. Secondary prevention strategies

38. Lifestyle modifications
 Tobacco
 Exercise
 Diet
Patients with normal physical activity
Moderate intensity exercise
(sufficient to break a sweat or noticeably elevation of heart rate)
for 150 minutes per week in bouts of 10 minutes or more
(But this patient having low EF she can not tolerate exercises)

39. Diet
 total calorie intake  based on the bodyweight
 eat at least five portions of fruit and vegetables per day
 Saturated fats should be replaced  mono- or poly-unsaturated fats
 Salt consumption should be minimized  less than one teaspoon
 No benefit from vitamin E, Vitamin B or calcium supplementation

40. Drug Therapy
 Anticoagulation
 Anti-platelet therapy
 Antihypertensive therapy
 Lipid lowering therapy
 Management of diabetes

41. Drug Therapy
 Should be started 10 days after the
stroke in previously untreated patients
whose blood pressure is persistently
elevated (SBP ≥140 or DBP ≥90 mmHg)
after TIA or stroke
 Target blood pressure should be
<130/80 mmHg
 ACE-I or ARB with CCB is indicated in
this patient
 Beta blockers are not indicated as
there is a history of bradycardia to
Labetalol
Antihypertensive therapy

42. Drug Therapy
 High intensity statin therapy
(atorvastatin 40-80 mg or rosuvastatin
20-40 mg)
 expected to reduce baseline LDL-C level
by 50%.
 use cautiously inpatients with a past
history of ICH have increased risk of
further ICH.
Lipid lowering therapy

43. Drug Therapy
 Enteric coated aspirin is preferred over
soluble aspirin for long term use
Anti-platelet therapy

44. Drug Therapy
 Glucose control to near normoglycemic
levels is recommended
 A goal of therapy is an HbA1C value of
≤7%
 Diet, exercise, oral hypoglycaemic
drugs, and insulin are proven methods
to achieve glycaemic control
Management of diabetes

45. Drug Therapy
 Brain imaging should be done to
exclude haemorrhage and blood
pressure should be under control
before starting anticoagulation
 In patients with stroke or TIA in atrial
fibrillation anticoagulation should be
started immediately with heparin
followed by warfarin
 In patients with a large cerebral
infarction and those with haemorrhagic
transformation in the initial imaging,
anticoagulation should be delayed up
to 14 days after the onset of stroke;
aspirin 300 mg daily should be
continued until then
Anticoagulation

46. Drug Therapy
 For patients in whom anticoagulation is
contraindicated, dual antiplatelet
therapy with aspirin and clopidogrel is
recommended
 Combination of oral anticoagulation
with anti-platelet therapy in atrial
fibrillation is not recommended unless
there is a cardiac indication for anti-
platelet therapy (e.g.: acute coronary
event, stent placement)
 For patients with ischaemic stroke
or TIA in the setting of
cardiomyopathy: Warfarin for 3
months with target INR 2.0 to 3.0 is
recommended if there is a left
ventricular mural thrombus
Anticoagulation

47. Drug Therapy
 For patients with atrial fibrillation (AF)
(persistent or paroxysmal),
anticoagulation should be the standard
treatment
 valvular AF
 Warfarin
 non-valvular AF
 Warfarin
 non-vitamin K antagonists / newer
oral anticoagulants
 Dabigatran
 Apixaban
 Rivaroxaban
 Edoxaban
Anticoagulation
 NOACs are of particular value in poorly adherent patients as they do not need
monitoring of anticoagulation

48. Drug Therapy
 For patients with ischaemic stroke or
TIA, in dilated cardiomyopathy with
ejection fraction < 35% or restrictive
cardiomyopathy without intracardiac
thrombi, the effectiveness of
anticoagulation compared with
antiplatelet therapy is uncertain and
the choice antithrombotic treatment
should be individualized
Anticoagulation

49. CHA₂DS₂-VASc Score
Score CHA2DS2-VASc Risk Criteria
1 point Congestive heart failure
1 point Hypertension
2 points Age ≥75 years
1 point Diabetes mellitus
2 points Stroke/Transient Ischemic Attack/Thromboembolic event
1 point Vascular disease (prior MI, PAD, or aortic plaque)
1 point Age 65 to 74 years
1 point Sex category (ie, female sex)

50. CHA₂DS₂-VASc Score
CHA2DS2-VASc
Score
Adjusted Stroke Risk, (% per year)
0 0
1 1.3
2 2.2
3 3.2
4 4.0
5 6.7
6 9.8
7 9.6
8 6.7
9 15.2
CHA2DS2-VASc Score Recommendation
0 None
1 None or aspirin or OAC
2 or more OAC
 Vitamin K antagonists
 Warfarin, with a goal INR of 2-3 and percent
time in therapeutic INR (TTR) remains ≥ 70%
 Direct Oral Anticoagulants
 Dabigatran
 Rivaroxaban
 Apixaban
 edoxaban
Oral Anti Coagulants

51. HAS-BLED Score for Major Bleeding Risk

52. HAS-BLED Score for
Major Bleeding Risk
CHA₂DS₂-VASc Score
for Atrial Fibrillation
Stroke Risk

53. Role of rehabilitation in stroke

54. Basics of rehabilitation
 formation of new connections in
cortex adjacent to the infarct
(axonal sprouting)
 formation of new neurons and
their migration to areas of injury
 recruitment and differentiation
of immature forms of glial cells
and physiological changes in the
responses of cortical circuits

55. Specific rehabilitation treatment strategies
 Therapies that comprise rehabilitation
include
 Psychological therapy
 Physiotherapy
 Occupational therapy
 Speech and language therapy
 Therapies focused on daily
function and community re-
integration

56. Hyper-acute Stroke Services
 Refers to centre where thrombolytic
therapy is available within 4.5 hours of
onset of symptoms
1. National Hospital of Sri Lanka
2. Teaching Hospital, Kandy
3. Teaching Hospital Jaffna
4. Teaching Hospital Karapitiya
5. Teaching Hospital Batticaloa
6. Teaching Hospital Anuradhapura
7. Teaching Hospital Kurunegala
8. District General Hospital, Kaluthara
9. Colombo South Teaching Hospital
10. Sri Jayewardenepura General Hospital
11. Polonnaruwa General Hospital

57. CREDITS: This presentation template was
created by Slidesgo, including icons by
Flaticon, infographics & images by Freepik
and illustrations by Stories
Thanks
Do you have any questions?
pamudith@dr.com

58. CREDITS: This presentation template was
created by Slidesgo, including icons by
Flaticon, infographics & images by Freepik
and illustrations by Stories
References
1. (Stroke. 2019;50:e344–e418.DOI: 10.1161/STR.0000000000000211.)
2. CCP Stroke guidelines 2017
3. Google MyMaps
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