Ischaemic stroke with left-sided hemiparesis – a case study
Prepared by the NORMAN Neurological Rehabilitation Centre.
This case study does not constitute medical advice and does not replace a consultation with a specialist or an individual diagnosis. For questions about your own health, please contact a doctor or physiotherapist.
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Patient details
Sex
Male
Age
62 years old
Main diagnosis
- ischaemic stroke in the region of the right corona radiata
- left-sided hemiparesis
- status post thrombolytic treatment of ischaemic stroke
Comorbidities
- hypercholesterolaemia
- patent foramen ovale with no visible shunt
- arterial hypertension under observation
- flaccid hemiplegia
- mild hypokinetic dysarthria in the resolving phase
- grade I diastolic dysfunction of the left ventricle
- nocturnal involuntary jerking of the left limbs with a sensation of tension and pain
Functional status
This case describes a sudden onset of superficial sensory disturbances in the left cheek and left hand. This was followed by a worsening of symptoms, with hypaesthesia of the entire left side of the body and a mild degree of weakness in the left limbs.
On neurological examination, full coherent contact was noted. Initially the striking findings were a less mobile left corner of the mouth, hypaesthesia of the left half of the face and a lower positioning of the left limbs in postural tests. Deep reflexes and muscle tone were reduced on the left side. Coordination tests were consistent with the paresis, with no meningeal signs and no pathological signs.
Over the following days, a deepening of the paresis was described. Central palsy of the left facial nerve of moderate degree was noted, with muscle strength of the left upper limb at 1/5 on the Lovett scale and of the left lower limb at 3+/5. A positive Babinski sign was present on the left side. No sensory disturbances were described at this stage.
In the later functional state, the patient remained in coherent contact. The left upper limb was flaccid, with muscle strength assessed at 0 on the MRC scale and no grip function, which was an indication for hand rehabilitation after stroke. The realistic pace of recovery of such function is an important consideration. Superficial and deep sensation were normal. In the left lower limb, muscle strength was assessed at 4 on the MRC scale, with normal superficial and deep sensation. The patient was independent in eating meals, moved around independently in a wheelchair and transferred independently from the wheelchair to a chair.
In terms of communication, normal comprehension of simple and complex commands, normal repetition of sentences, fluent reading and undistorted handwriting were described. Speech was slightly slowed, with occasional stumbling over difficult consonant clusters. In logical, lexical and grammatical terms it was correct. Slight hoarseness and asymmetry of the tongue and lips to the disadvantage of the left side were noted. The patient reported no difficulties of a dysphagic nature. On later assessment, speech comprehension was complete, active speech was undisturbed, phonation was unimpaired and swallowing was effective.
On psychological assessment, full personal and situational orientation, a coherent train of thought, undisturbed thought structure, a balanced baseline mood and an affect appropriate to the content expressed were described. No significant abnormalities were noted in memory, executive function, visuospatial function or language function.
Significant medical events
Magnetic resonance imaging of the head described a subacute ischaemic lesion in the right corona radiata. Computed tomography of the head showed no features of intracranial bleeding. CT angiography of the arteries supplying the head showed no features of stenosis, and no clear features of embolic material, aneurysmal dilatation or vascular malformation were visualised.
In this case an EEG was also performed, in which the recording was described as normal. Holter ECG showed no atrial fibrillation or flutter, no ventricular arrhythmias and no significant pauses. Occasional atrial extrasystoles were noted. Echocardiography described a normal left ventricular ejection fraction, mild septal hypertrophy, relaxation disturbances, mild atrioventricular valve regurgitation and features of a patent foramen ovale with no visible shunt.
Isolated episodes of involuntary jerking of the left limbs occurring at night were also noted, accompanied by a sensation of tension and pain in the limbs. Following the treatment applied, a significant improvement in these symptoms was described.
Patient status on completion of hospital treatment
On completion of hospital treatment, the patient was verticalised to walk on a flat surface with the aid of an elbow crutch and with supervision, which required further work on gait and balance disorders. Left-sided hemiparesis persisted, more pronounced in the left upper limb.
Further rehabilitation, specialist consultations and neurological, cardiological and haematological reviews were recommended. Monitoring of pulse and blood pressure values and physical activity adapted to the patient's capabilities were also indicated.
Next stage of rehabilitation
On completion of hospital treatment, the patient continued the rehabilitation process. On admission for the next stage of rehabilitation, he was assessed at 9 points on the Barthel ADL Index. On functional assessment, the striking findings were the absence of grip function in the left hand, flaccidity of the left upper limb, preserved independence in eating meals, independent mobility in a wheelchair and independent transfer from the wheelchair to a chair.
In the further course, optimal functional improvement was noted, without significant improvement in the function of the left upper limb, which underscored the need to continue therapy for hand and upper limb paresis.
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