Ep 152: A 66-Year-Old with Inability to Speak
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This is Katarina Heidhausen, executive editor of Harrison's Principles of Internal Medicine. Harrison's podcast is brought to you by McGraw-Hill's Access Medicine, the online medical resource that delivers the latest content from the best minds in medicine. And now, on to the episode.

The 22nd edition of Harrison's is now live on Access Medicine. Click the link in the show notes and sign in with your institutional subscription to access the full book, over a thousand review questions, and more. Look for the print edition coming later this summer. Hi, everyone. Welcome back to Harrison's Podcast. We're your co-hosts. I'm Dr. Kathy Handy. And I'm Dr. Charlie Wiener, and we're joining you from the Johns Hopkins School of Medicine. Welcome to today's episode, which is a 66-year-old with the inability to speak.

Kathy, today's patient is a 66-year-old man with a past medical history of hypertension, diabetes, and hyperlipidemia. He's brought to the emergency department by his spouse, who reports that he's having the second episode of inability to articulate words and hold things in his right hand. He had a similar episode yesterday while taking a walk, but he rested and felt back to normal within 30 minutes. He denied any chest pain or palpitations at the time.

This morning, while watching the news, he started garbling his words and he dropped his coffee out of his right hand. First, I'm worried that he's having a stroke. I want to move quickly, but tell me some more about his past history and his physical exam while we get ready to send him to the CT scanner. Okay, well, as I mentioned, his past history is notable for hypertension, diabetes, and hyperlipidemia, and his medications include amilodipine, metformin, and atorvastatin. He's never been hospitalized except for a torn ACL in his 40s.

His last hemoglobin A1C was 6.5%. He's a retired sports announcer, quit smoking 20 years ago, and is up to date on his routine screening. He had a negative exercise stress test three years ago. And his physical examination now? So his blood pressure is 130 over 80, his heart rate is 75, his respiratory rate is 12, his oxygen saturation is 98% on room air, and he's afebrile.

Other than an S4, his entire physical examination is normal. His spouse said his symptoms went away again while she was driving him to the hospital. So what was the total duration of his symptoms this time? She estimates 60 to 90 minutes at most.

Okay, so we're talking about a stroke here. Wait, he's having a stroke? A stroke is defined as an abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. Thus, the definition of stroke is clinical, and laboratory studies, including brain imaging, are used to support the diagnosis. So yes, I'm worried he's having a stroke, but I know you're not going to let me off that easy. I've seen a lot about stroke in the media lately. Sounds like it's a growing problem in the U.S.,

It's the second leading cause of death worldwide, and it's increasing since 2000. In 2016, the lifetime global risk of stroke from age 25 years onward was 25%, and that's an increase of almost 10% from 1990. The prevalence is also rising in the U.S., and stroke is the second most common disabling condition in adults over 50. But there is good news. Due to greater awareness and better treatment, case-specific, disability-adjusted life years due to stroke are falling.

Okay, well, that's a good segue to our question, which asks about some of those issues. The question asks, which of the following statements regarding this patient is true? Option A is, he's having a TIA that is likely due to a hemorrhage. Option B is, his risk for ischemic stroke in the next three months is over 50%. Option C is, he should receive aspirin treatment. Option D is, he should receive aspirin plus ticagrelor treatment.

Or option E is he should receive systemic or directed thrombolysis within 90 minutes. Let me step back for a second. Neurologic symptoms are seen in patients within seconds because neurons lack glycogen, so energy failure of those cells is rapid. If the cessation of flow lasts for more than a few minutes, infarction or death of brain tissue results.

When blood flow is quickly restored, brain tissue can recover fully and the patient's symptoms are only transient. And in that case, the patient develops a TIA. The definition of TIA requires that all neurologic signs and symptoms resolve within 24 hours without evidence of brain infarction on brain imaging.

Stroke has occurred if the neurologic signs and symptoms last for over 24 hours or brain infarction is demonstrated. Okay, so this patient's having a TIA or a transient ischemic attack, right? Yeah. Okay, then are TIAs caused by hemorrhage? That's what option A is asking. No, that's typically not true. Intracranial hemorrhage is caused by bleeding directly into or around the brain.

It produces neurologic symptoms by three potential ways. One, by producing a mass effect on neural structures. Two, from the toxic effects of blood itself. Or three, by increasing intracranial pressure. TIAs are typically ischemic events from transient occlusion of a blood vessel or sometimes due to small emboli that clear quickly.

Option B asks if TIAs are harbingers of ischemic stroke within the next three months. That is partly true. The risk of stroke after a TIA is about 10 to 15 percent in the first three months. Most events occur within the first two days. Therefore, urgent evaluation and treatment are often justified. Because etiologies for stroke and TIA are identical, evaluation for TIA should really parallel that of stroke. Is there a way of estimating this patient's risk?

The risk of stroke following a TIA can be estimated using the well-validated ABCD2 score. That takes into account the patient's age, blood pressure, clinical presentation, and presence of diabetes. Based on his presentation, our patient would have a 15 to 20% chance of stroke in the next three months. So it's not 50%, but the risk is substantial and warrants treatment. Which brings us to the last three options.

Okay, well, the answer is D. So he should get dual antiplatelet therapy with aspirin and either ticagrelor or clopidogrel. A number of studies have demonstrated the superiority of dual antiplatelet therapy over just aspirin. Ticagrelor may be better overall because failure to respond to clopidogrel is linked to carriage of a common CYP2C19 polymorphism that leads to poor metabolism of clopidogrel into its active form.

This mutation is common, especially among some populations. The metabolism of Cagrelor is more consistent with less genetic variability. What about thrombolysis? Thrombolytics clearly work in stroke. However, the transient nature of TIAs is a contraindication to thrombolysis. That being said, because the risk of subsequent stroke in the first few hours and days following TIA is high, some physicians admit the patient to the hospital so a plasminogen activator can be rapidly administered if symptoms return.

Great. So today's case has a few teaching points. One is that stroke is a clinical definition. When a patient has a stroke symptoms that disappear within 24 hours, they can be said to have had a TIA or again, transient ischemic attack. The presence of TIA does put the patient at risk of stroke within days to months. So treatment and further evaluation is in order. Patients with TIA should be treated with dual antiplatelet therapy.

And you can find this question and other questions like it on Harrison's self-review. And you can read more about this topic in the Harrison's chapter on cerebrovascular disease and ischemic stroke. Visit the show notes for links to helpful resources, including related chapters and review questions from Harrison's, available exclusively on Access Medicine. If you enjoyed this episode, please leave us a review so we can reach more listeners just like you. Thanks so much for listening.