REASON FOR CONSULTATION: Pontine stroke.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-handed Hispanic female, who developed left arm numbness and dysarthria during an adenosine stress test. She went home and became progressively weaker in the legs. Her symptoms did not improve over several hours. She became incontinent and returned to the hospital, apparently, overnight. She did not receive TPA because of the course of her disease and also because she was fully anticoagulated with Coumadin per her history of paroxysmal atrial fibrillation, prior CVA, and ventricular aneurysm. She was brought from the local emergency room for supportive care. A CT on the day of admission showed nothing. MRI and MRA showed large ventral pontine stroke. An angiography showed moderate irregularity and stenosis of the distal vertebral arteries, although everything was patent. As a result, she deteriorated to the point where she had a quadriparesis, right sixth nerve palsy.
G-tube was placed, and she did not apparently have to be intubated. Upper GI bleed also developed, after the G-tube had been placed. She was transfused with blood and had EGD the next day. This showed a massive clot in the stomach, and anticoagulation was not started for another two days as a result. After that, she remained stable with stable hemoglobin and no further GI bleeding. She developed no AF during her stay but remained on amiodarone with a rate in the 50s to 60s. It was concluded that she should be on chronic anticoagulation after discharge due to stenosis within the posterior circulation and her paroxysmal AF. She had good O2 saturations on room air.
PAST MEDICAL HISTORY: Significant for hypertension, hyperlipidemia, low back pain, narcotic dependent, prior CVA though we are not sure where this is located, paroxysmal atrial fibrillation, MI with a ventricular aneurysm, history of cervical cancer, and diabetes.
FAMILY MEDICAL HISTORY: Unknown.
SOCIAL HISTORY: The patient smokes two packs per day. She lives alone. She had four adult children. She has a history of med noncompliance secondary to affordability.
REVIEW OF SYSTEMS: Limited. The patient is reliable for yes/no information; however, she cannot communicate much beyond that. She follows all commands if she can. She does deny troubles during sleep, and she denies pain at this time.
PHYSICAL EXAMINATION: Temperature 97.8, pulse 56, respirations 21, and blood pressure 140/68. She is alert. She answers yes/no reliably with a head nod. She follows simple commands. She is unable to articulate at all. Her cognitive evaluation, mental status are otherwise limited.
Pupils are equal and reactive, minimally so. Fundi are poorly visualized. Extraocular movements show nystagmus on attempted gaze to the left and right esophoria. She has a right sixth nerve palsy with gaze to the right. She has full duction in the left eye.
Could not examine her palate because her tongue was large and she was unable to protrude it and unable to elevate her palate. Swallow is extremely impaired by palpation of the neck.
Motor examination shows trace movement in the right adductors and shoulder extensors. There is trace movement in the elbow on flexion and extension, and there is trace movement in flexion of the fingers of the right hand. Otherwise, she has no voluntary movement anywhere in the rest of her body. Reflexes are brisk everywhere. She has clonus, unsustained, in both ankles. Toes are upgoing. She has intact primary sensation for pain, temperature, JPS, and vibration.
Gait and cerebellar exams could not be done.
IMPRESSION: Pontine infarct with bilateral injury affecting the entire pons, mostly ventral pons and right sixth nerve nuclei. Lower cranial nerves, at least IX-XII are significantly impacted bilaterally and suggest a basilar artery perforator disease. The patient had a very ectatic basilar artery, and it is likely that she had thrombus occluding her basilar and affecting perforator flow to cause this diffuse ventral pontine injury.
At this point, she is quadriparetic but is not locked in. She has reasonably good eye movements. She has a head nod. She is very much alert and cognizant of her surroundings and care needs to be taken about discussions in front of her, which she cannot verbally participate in. Additionally, she has early return in the right arm, even distally, which is an encouraging sign for functional use of the right extremity.
RECOMMENDATIONS:
1. Bowel program once her C. difficile and diarrhea gets cleared with a suppository at night and fiber during the day.
2. The patient could be put on a voiding trial. Once she gets her setup with the environmental control, she needs to call the nurse.
3. The patient needs to be evaluated by Speech and OT for environmental control assistance for which she could use head nods or eye movements.
4. PT needs to get this patient out of bed and tilt-in-space wheelchair ASAP and drive her sitting tolerance into the 46-hour-day range. Proper positioning will improve her spasticity, which is going to clearly develop. At this time, we will not treat her with oral medications unless she fails more conservative physically-based measures.
Prognosis for improvement is unclear at this time. She has significant medical comorbidities and significant heart dysfunction, which will limit the amount of physical activity she can tolerate. She is now approximately two weeks off from the stroke, with early return in the right arm which is a good prognosis for arm recovery, however, further evaluation serially will help us understand better how better her tone will be in the lower extremities.
Extra care needs to be taken to ensure that the skin remains intact and that DVT risk is minimized by continued anticoagulation of the patient for both stroke prophylaxis and DVT prophylaxis.
