70yr old with recurrent CVA

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CASE:
A 70 year old male patient was brought to casualty with c/o weakness of right upper and lower limbs and slurring of speech since 3 days

HISTORY OF PRESENTING ILLNESS:
=> Patient was apparently asymptomatic 3 years back when he developed weakness of right upper and lower limbs and was managed conservatively
=> He had a second similar episode of weakness of right upper and lower limbs and slurring of speech one year back and was managed conservatively
=> He again had a similar episode for 3rd time 3 days back which is weakness of right upper and lower limbs and slurring of speech while having his breakfast on 3/6/2022 and was brought to hospital on 6/6/2022

HISTORY OF PAST ILLNESS:
=>Patient is a known case of hypertension since one year and was using T.Aten 25mcg since then
=>Pt is not a K/C/O DM, TB, ASTHMA, EPILEPSY, CAD

PERSONAL HISTORY:
Diet: mixed
Sleep: adequate
Appetite: normal
Addictions: 
*Patient is an occasional drinker 10 years back but stopped drinking from 10 years
*Non smoker
ON EXAMINATION:
Pt is C/C/C
Vitals at admission:
Temp: Afebrile
BP:140/80mmhg
PR: 72 bpm
RR: 20 cpm
SpO2: 98% @ RA
GRBS: 193mg/dl

SYSTEMIC EXAMINATION:
P/A: soft, non tender, no guarding/rigidity
CVS: S1S2 +
RS: BAE +
CNS:
Higher mental functions: Intact, no delusions or hallucinations
                      RT.                           LT
TONE: UL.     Hypotonia              N
             LL.     Hypotonia.            N

POWER: UL.   0/5.                       5/5
                LL.   0/5.                      5/5

REFLEXES: B.     +++.                    ++
                    T      +++.                    ++
                    S.     +++.                    ++
                    K      +++.                    ++
                    A.     +++.                    ++
                    P.      Flexion.             Flexion

DYSDYNOKINESIA


INVESTIGATIONS:





PROVISIONAL DIAGNOSIS:
ACUTE ISCHEMIC STROKE
RT HEMIPLEGIA
? Lt MCA territory
Recurrent CVA

TREATMENT:
1. T.ECOSPIRIN 150mg P/O OD
2. T.CLOPRIDOGEL 75mg P/O OD
3. T.ATORVAS 40mg P/O H/S
4. T.PAN 40mg P/O OD
5. T.ATEN 25mg P/O OD
6. Physiotherapy of RT UL AND LL
7. Monitor vitals


ON 11/6/2022
Location:-Ward——>AMC

S:- pt is making in comprehensible sounds & responding only to painful stimulus at 8:00am

At 12:00pm Pt consciousness improved,following commands,but making incomprehensible sounds 

Initially presented 5day’s back with slurring of speech,Weakess of Rt UL & LL
After 2day’s  Pt LL power improved from 0/5 to 3/5 

today 2am pt went to bathroom on his own,his wife noticed in the morning 7am that  he is not able to get up from bed & had weakness of right lower limb & making in comprehensible sounds

O:-
E2V2M4(8am)——->E4V2M6(12pm)
Bp-130/80mmhg
Pr-84/min
CVS-S1S2 +
RS-B/LAE +
CNS-                   
                            Rt.               Lf
      
  Tone:-UL.       Hypo.            N
              LL.       Hypo.            N

Power- UL         0/5                4/5
               LL.        0/5.              4/5

Reflexes- B.         3+              2+
                  T.         3+.             2+
                  S.         3+.             2+
                  K.         2+.              2+
                  A.         1+.              1+
                  P.         Extensor.    Flexor
     
Pupils :- B/L constricted reacting to light

Sr electrolytes     ABG
Sr Na-143.            PH-7.4
Sr k.  -3.6.             Pco2-28.2
Sr cl  -96.              Hco3 -18.5
                                Po2-86.8
                                So2-95

Carotid doppler-
Rt CCA-70% Luminal narrowing
Lf CCA-90% Luminal narrowing

A:- Acute CVA Rt hemiplegia(?MCA infarct) with h/o Recurrent CVA 
With denovo detected DM2 with HTN(since 1yr)

P:-Repeat MRI for any extension of infarct or Hemorrhagic transformation of infarct

Questions
1)Reason for sudden deterioration of  pt condition

2)Is thrombectomy  & carotid stenting useful in this patient to prevent further stroke 

3)cause of his recurrent stroke??

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