Aphasia during a Transatlantic Flight

Posted by • April 28th, 2016

2016-04-25_11-01-53In more than 60% of patients with ischemic stroke, the cause is readily established and is most often atherosclerosis or heart disease. However, in a young patient with no traditional vascular risk factors and a large clot burden, the search can be broadened to include, at minimum, thrombophilia, arterial dissection, paradoxical embolism, and unusual arteriopathies.

A 49-year-old woman was brought to the ED 2 hours after the onset of hemiplegia and aphasia during a transatlantic flight. Examination revealed evidence of acute ischemic stroke. Additional diagnostic studies were performed. A new Case Records of the Massachusetts General Hospital summarizes.

Clinical Pearl

• What is the Cincinnati Prehospital Stroke Scale?

The Cincinnati Prehospital Stroke Scale, which screens for three symptoms (facial droop, arm drift, and speech disturbance) that may occur with stroke, is based on the larger National Institutes of Health Stroke Scale (NIHSS). One point is designated for each abnormal finding, and a score higher than 0 triggers a stroke alert. The Cincinnati Prehospital Stroke Scale has shown excellent correlation between prehospital providers’ suspicion of stroke and physicians’ confirmation of stroke.

Clinical Pearl

• What is the May–Thurner syndrome?

The May–Thurner syndrome is a common anatomical anomaly in which the right common iliac artery, a muscular structure, extrinsically compresses the thin-walled left common iliac vein. This anatomical feature of the May–Thurner syndrome was identified in up to 25% of an asymptomatic population; none of these patients had unilateral edema or a history of deep venous thrombosis of the legs. Among patients with cryptogenic stroke and patent foramen ovale, the prevalence of the May–Thurner syndrome is 6.3%.

Figure 2. Additional Imaging Studies.

Morning Report Questions

Q: What do guidelines indicate for the prevention of recurrent stroke in patients with an ischemic stroke and patent foramen ovale?

A: For patients with ischemic stroke and patent foramen ovale and without definitive evidence of deep venous thrombosis, guidelines indicate that the current data are insufficient to establish whether anticoagulation is equivalent or superior to aspirin for the prevention of recurrent stroke, and available data do not support a benefit of patent foramen ovale closure. In a recent meta-analysis including a total of 4251 patients, those who had stroke with patent foramen ovale did not have a higher risk of either recurrent stroke or the combination of stroke and transient ischemic attack than did those who had stroke without patent foramen ovale. However, for patients who have both a patent foramen ovale and a presumed venous source of embolism, anticoagulation is generally indicated. When anticoagulation is contraindicated, because of an increased risk of intracranial or systemic hemorrhage, then placement of an inferior vena cava filter is a reasonable option.

Q: What is the risk of venous thromboembolism in patients with cancer, and what may influence the risk associated with renal cancer?

A: The rate of venous thromboembolism among patients with cancer varies according to tumor factors (including tumor type, the presence or absence of metastasis, and the anatomical features of the tumor) and the patients’ baseline risk factors and previous and current therapies. Approximately 20% of first venous thromboembolic events occur in patients with cancer; the risk of venous thromboembolism among patients with cancer is 4 to 7 times as high as the risk among those without cancer. Patients with renal-cell carcinoma, particularly those with metastases, often present with elevated levels of fibrinogen, d-dimer, and fibrin monomers. Immunofluorescence staining with the use of antibodies specific for fibrin and factors VII and X has shown positivity around intravascular and extravascular nodules of renal-cell carcinoma tumor cells, thus raising the possibility that tumor cells activate coagulation locally.

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