Maria Dimitrova, a 28 year-old Czech woman is excited to be emigrating to New Zealand with her partner, Joseph. Maria and Joseph transit via Frankfurt and Singapore, before finally arriving in New Zealand some 35 hours since their departure from Czech Republic. Although taking the combined oral contraceptive pill, Maria secretly wonders if she is pregnant because she has been feeling nauseated throughout the journey. When the meals and fluids are served, Maria takes very little of the fluid and refuses at least three meals. She feels uncomfortable seated between Joseph and another man on the longest flight, so she elects to only get up from her seat when she really needs to go to the toilet, thankfully not often at all because she isn’t drinking much fluid. Arriving in Auckland, Maria complains of a swollen right foot and she has pain and swelling in the calf of her right leg.
The couple take just one more flight to Christchurch where they finally check in to their hotel for some decent rest. At 4.30am in the dark, Joseph is awoken by a ‘thud’ and the sound of Maria groaning. He turns on the light and finds Maria collapsed on the tiled bathroom floor. He thinks she must have passed out, but something seems not right when he attempts to rouse her and he sees blood on the tiles. Not sure what to do, Joseph phones the night reception in the hotel who call emergency services.
Question 1 [20 minutes]
Q1a. Outline the approach paramedics should take in both assessing and managing Maria on their arrival at the hotel.
- DRSABCDS
- Try to get as much info from joseph as possible
- Assess GCS and NIHSS and vitals
Q1b. Using only the information you have so far, name three[3] possible causes for Maria’s collapse. For each possible cause state:
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The likelihood of this cause occurring in a young woman, such as Maria.
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Your rationale for including this possible cause for Maria’s collapse, including any features of the presentation which may not support it.
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Two[2] questions the ED house officer could ask to help either rule in or rule out that cause.
ischaemic stroke uncommon DVT + patent foramen ovale can lead to CVA, additionally pregnancy is a hyper coagulative state, leading to higher chances of emboli formation nothing that currently discounts stroke
do you have a patent foramen ovale have you recently had symptoms of TIA
Cerebral haemorrhage rare preeclamsia is a condition in pregnancy which can lead to cerebral haemorrhages,
Have you had vision changes have you had severe headaches
TBI could have slipped on a wet bathromm floor and been concussed joseph doesnt know how she ended upon the ground.
ask her what happened ask is she had been feeling dizzy or fallen recently
Clinical Update
ED doctors record the following. Twenty-eight year-old female of Czech nationality brought in by ambulance to ED approximately 1 hour 20 minutes post-collapse at 0.430hrs. Accompanied by her partner, who found the patient collapsed on the bathroom floor of their hotel. Patient drowsy and disorientated to time and place, but cooperative. Eye-opening to speech GCS 13-E3, V4, M6. Dysphasic [slurred speech]. Pupils equal and reacting to light. There is right-sided weakness, arm >leg. She also exhibits a right-sided facial paralysis affecting the lower face. Patient appears clinically dehydrated and is noted to have a swollen foot and calf on the right. Some tenderness and erythema over the calf swelling. No swelling noted over the left extremity. Chest is clear on auscultation. No audible murmur. No signs of jugular venous distention. No bruits.
Head and neck: Some tenderness over the occiput, but minimal swelling and minor head wound, not requiring suturing. No neck stiffness. Partner reports the couple flew from Prague, landing in NZ yesterday afternoon. He also states the patient wondered whether she may be pregnant.
Vital signs Temp 37.1 BP 142/86 Pulse 80/reg O2 sats 97% on room air Blood glucose normal ECG shows normal sinus rhythm
Past Medical History Suffers from migraines, otherwise nil of note. Denies having any previous episodes of slurred speech, ataxia, numbness. Denies previous feet/leg swelling. Denies having any chest pain or dyspnoea. No known allergies. Medications: On combined oral contraceptive pill for past 8 years. No complementary or alternative medicines but drinks Elderberry tea.
Social History Moving with partner to NZ to live and work permanently. Presently in hotel. Social smoker Drinks only occasionally No recreational drug use
Family History Mother has hypertension and is on meds. Father had MI aged 50, presently on meds and said to be well. No siblings
Bloods drawn revealed elevated LDL and total cholesterol, a decrease in mean cell volume and a raised haematocrit consistent with dehydration. Other blood results were unremarkable. A urine sample returned a negative pregnancy test.
Q1c. Reviewing the findings so far, what possible risk factors [modifiable and non-modifiable] does Maria carry for Stroke?
hypertension, possible migraine with aure, and contraceptive pill all multiply risk factors, dehydration is a risk factor for stroke. social smoking is a risk factor. genetic risk factor from Cardiovascular incident in father
Q1d. If this were Stroke, what hemisphere in the brain is likely affected and in what cerebral territory? [be as precise as you can]
left MCA around arm and face centre. (So lateral on the precentral gyrus)
lower face droop shows that UMN for area affected, as upper face muscles are innervated bilaterally.
Question 2 [15 minutes]
Clinical Update
Maria undergoes urgent head CT with head and neck CTA [CT angiogram]. Doppler ultrasound of her right calf is also performed. CT reveals a discrete hyperdensity suspicious for thrombus in the left middle cerebral artery [MCA]. CTA confirms a clot sitting proximally in the vessel causing a large perfusion deficit. Maria is administered tissue plasminogen activator [tPA]. MRI confirms the exact territory and extent of the ischaemic infarct and an interventional radiologist performs mechanical thrombectomy, successfully removing a 0.8cm clot from the MCA. Once stabilized, Maria undergoes a trans-oesophageal echocardiogram which reveals a Patent Foramen Ovale [PFO].
Q2a. Describe in as much detail as you are able, the vascular mechanism[s] and vessels/structures involved in Maria sustaining an ischaemic [thrombo-embolic] Stroke involving the left middle cerebral artery. You may use a flow diagram to support your answer.
Maria has sustained a Deep Vein Thrombosis due to hypercoagulative factors and this embolised to the heart and then through the patent foramen ovale, where it travelsed tot he arterial circulation and embolised to the brain where it got stuck in the left middle cerebral artery.
Q2b. Considering Maria’s presentation and the results of her investigations, list the salient features pointing to this mechanism.
DVT formed with swelling and pain in right leg, due to hypercoagulative state and long periods of static position. this embolised through foramen ovale which was also found
Clinical Update
Maria makes a good recovery and is able to be discharged from hospital with very minimal neurological deficit. She is expected to make a full recovery, but is required to take dabigatran and labetalol, with cardiology and haematology follow-up. Eighteen months later, Maria has her PFO successfully closed by an interventional cardiologist. One year following, Joseph and Maria welcome their first child, Ricci into the world.
Clinical Update
At two years of age, Maria is worried Ricci seems to be different compared to the other children his age. He doesn’t talk much to other kids, has difficulty sustaining his attention and cannot sit still at times. He screams when she has to leave him at daycare to go to work. Ricci also becomes easily frustrated and throws some huge tantrums and has even hurt other children. Maria asks her Plunket Nurse if Ricci’s behaviours are normal for his age.
Q3a. Use your knowledge of the cognitive, emotional, social and language skills of a two year-old, and any contextual elements you think relevant, to answer Maria’s question.
yeah austism 50/50