RT Book, Section
A1 Mazzarelli, Joanne
A1 Werns, Steven
A2 Lee, Kiwon
SR Print(0)
ID 1101644516
T1 Acute Coronary Syndrome
T2 The NeuroICU Book
YR 2012
FD 2012
PB McGraw-Hill Education
PP New York, NY
SN 9780071636353
LK neurology.mhmedical.com/content.aspx?aid=1101644516
RD 2024/04/23
AB A  67-year-old  man  with  a  history  of  hypertension,  hyperlipidemia,  and  tobacco  use  was  found  by  family  members  with  left-sided  paralysis,  rightward  eye  deviation,  and  change  in  mental  status  and  was  brought  to  the  emergency  department  (ED).  Computed  axial  tomography  (CAT)  of  the  brain  performed  in  the  ED  (Figure  31-1)  showed  a  large  acute  nonhemorrhagic  right  hemispheric  infarct  within  the  vascular  territory  of  the  right  middle  cerebral  artery.  The  infarct  involved  large  portions  of  the  frontal,  temporal,  and  parietal  lobes  as  well  as  underlying  basal  ganglia  structures.  The  proximal  right  middle  cerebral  artery  was  hyperdense,  consistent  with  thrombosis  within  the  vessel.  The  patient  was  not  administered  thrombolytic  therapy  because  of  the  unknown  onset  of  symptoms.  The  local  ED  physicians  decided  to  transfer  the  patient  immediately  to  the  nearest  tertiary  medical  center.  On  arrival  to  the  intensive  care  unit,  the  patient  was  awake  and  alert  but  with  a  left  hemiparesis  and  left  hemineglect.  Upon  admission  he  complained  of  dyspnea  but  no  chest  pain.Heart  rate  (HR)  was  77  bpm  and  regular,  blood  pressure  (BP)  89/55  mm  Hg,  respiratory  rate  (RR)  15  breaths/min,  temperature  (T)  36.5°C  (97.7°F),  and  arterial  oxygen  saturation  (Sao2)  98%  on  6  L  oxygen.  Cardiovascular  examination  was  notable  for  jugular  venous  distention  with  an  estimated  jugular  venous  pressure  of  9  cm  H2O.  The  first  and  second  heart  sounds  were  noted  to  be  normal  and  regular.  There  was  a  III/VI  holosystolic  murmur  at  the  apex.  The  lungs  were  clear  to  auscultation  bilaterally.  Initial  laboratory  test  results  were  notable  for  a  blood  urea  nitrogen  (BUN)  of  65  mg/dL,  creatinine  of  1.5  mg/dL,  white  blood  cell  (WBC)  count  of  16,700/μL,  hemoglobin  (Hb)  of  12.2  g/dL,  and  platelets  of  413,000/μL.  Cardiac  biomarkers  were  elevated  with  a  creatinine  kinase  of  821  U/L,  a  troponin  T  of  4.33  ng/mL,  and  a  creatine  kinase  MB  (CK-MB)  of  12.0  ng/mL.  An  electrocardiogram  (ECG)  and  chest  x-ray  were  performed  on  admission  (Figures  31-2  and  31-3).