CASE REPORT
RECURRENT STROKE: WHAT HAVE WE LEARNT?
Rabia K, MMed(FamMed)
EM Khoo, MRCGP, FAMM, FAFP (Hon)
Dr Rabia Khatoon and Professor Khoo Ee Ming are from the Department of Primary Care Medicine, Faculty of Medicine University of Malaya, Kuala Lumpur, Malaysia.
Address for correspondence: Dr. Rabia Khatoon, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Fax number: 03- 79577941, Email: akim@streamyx.com, rabia@um.edu.my
Conflict of interest: none
ABSTRACT
Stroke is the third leading cause of death, a major cause of disability in adults, and is frequently more disabling than fatal. With a decline in mortality from initial cerebral infarction and an increase in the life expectancy of the population, the number of patients with recurrent stroke and ensuing cardiovascular events will become greater. Thus it is important to find out those patients at high risk of stroke recurrence. This case report illustrates the process of recurrent stroke and the resulting disabilities and morbidities in a 42-year- old man. The role of integrated stroke rehabilitation programme is described.
Key words: Stroke, rehabilitation, prevention.
CASE SUMMARY
History
Mr. BS, a 42-year-old Punjabi man was diagnosed with hypertension for more than thirteen years and diabetes mellitus for more than nine years. He had been under the care of his general practitioner. He presented to a private centre with progressive weakness of the left upper and lower limbs, slurring of speech and left sided facial weakness in the year 2003. His CT brain showed evidence of recent infarction in the right frontal white matter. He was commenced on aspirin, atenolol, enalapril, metformin, gliclazide and lovastatin. He was then discharged and referred to us for intensive physiotherapy of the limbs to ensure good recovery of his motor power. Further history revealed that he had two previous episodes of stroke in the past one month with similar findings although he had fully recovered from these episodes and had no urinary or bowel incontinence.
In the past medical history he had a transient ischaemic attack (TIA) in 1994, when he was first diagnosed to have hypertension. His electrocardiogram, echocardiogram, connective tissue screening, protein C and S, antithrombin III were normal although his lipid profile was deranged. Cerebral angiogram showed a small atherosclerotic plaque in the posterior wall of the right internal carotid artery. He was discharged on aspirin 300 mg daily, nifedipine 10 mg tds and lovastatin 20 mg at night. Subsequently he defaulted follow-up. In 1997 he was diagnosed to have diabetes mellitus. His lifestyle was rather sedentary. His mother was hypertensive and his father had diabetes mellitus. He was a non-smoker but consumed beer occasionally. He worked as a security guard before the first episode of stroke.Physical findings
On examination he could walk independently without aid. He was orientated in time, place and person but had slurred speech. His BMI was 30 kg/m2, blood pressure was 140/80 mmHg, pulse rate was 74 beats per minute, regular rhythm with good volume. There was no carotid bruit and his cardiovascular, respiratory and abdominal examinations were normal. There was an upper motor neuron lesion of the left 7th cranial nerve. His lower limb reflexes were brisk, foot sensations were intact, motor power was 4/5 in the left upper limb and lower limbs, and his left plantar was up-going. There were no signs of peripheral neuropathy.
Investigations
His laboratory tests are shown in table 1. His CXR and ECG were normal and his magnetic resonance angiography showed right internal carotid stenosis.
Referral
He was referred for physiotherapy, dietitian and eye clinic for assessment of diabetic retinopathy. He was seen by a neurologist and was advised to stop aspirin and started on clopidogrel 75 mg daily in view of recurrent events of stroke.
