Cerebrovascular Accident, Cervical Myelopathy, or Both?
Faculty Sponsor’s Department
Internal Medicine
Type
Oral Competitive
Project's Category
Neurological Disorders
Abstract or Artist's Statement
Cerebrovascular accidents are a leading cause of morbidity and mortality in the United States. Many conditions exist which may mimic this disease process including seizures, migraines, metabolic derangements, infections, space-occupying lesions, neurodegenerative disorders, peripheral neuropathy, cervical myelopathy, syncope, other vascular disorders, and functional neurologic disorder. Timely diagnosis and treatment are important in order to preserve functional status in these patients. A 48-year-old male presented to the emergency department with a 28-hour history of worsening left sided numbness, tingling, weakness, and feeling off balance. The patient stated that for the past several months he had noticed these symptoms, but they suddenly became worse the day prior. He also described shooting pains down the left arm with certain movements of his neck. The patient denied any difficulty with speaking, understanding words, performing mental tasks, bowel or bladder incontinence, or right sided symptoms. Physical exam showed intact cranial nerves II-XII, 5/5 strength of upper and lower extremities on the right side, 4/5 strength of upper and lower extremities on the left side. Romberg test was normal, heel to shin and finger to nose were intact bilaterally. Foot drop was noted on the left side and placement of the foot on the ground was noted to be clumsy. Initial head CT in the emergency department showed a frontal lobe hypodensity and was without intracranial hemorrhage. Computed tomography angiography of the head and neck showed no large vessel thrombosis or stenosis. Echocardiography revealed normal chamber sizes, normal left ventricular ejection fraction, no patent foramen ovale, and no left atrial or left ventricular thrombus. Telemetry monitoring throughout the stay remained sinus rhythm. Magnetic resonance imaging of brain and cervical spine was performed showing multifocal acute infarcts of the right and left frontal lobes and severe cervical spondylosis at C4-C6 with spinal cord edema in T2 sequences slightly below that level. The patient subsequently underwent a cervical spine decompression for the spinal cord compression during the hospital stay. Due to the multifocal lesions noted on the brain MRI, a vasculitis workup was performed which returned negative for any abnormal test findings. The patient was also diagnosed with diabetes mellitus type 2 during the stay as he was found to have a glycosylated hemoglobin A1C of >12. He was initially hypertensive during hospitalization, but this resolved on its own after day three of the hospitalization so anti-hypertensives were not required. The patient was discharged home on high intensity statin therapy, dual oral hypoglycemic therapy for his diabetes mellitus, home physical therapy, and he was scheduled to start dual antiplatelet therapy seven days after cervical spine surgery. This dual antiplatelet therapy with clopidogrel and aspirin was to be continued for three weeks after which continuation with low dose aspirin was advised. As seen in this case, patients that present with a cerebrovascular accident should always be evaluated for other etiology behind his or her symptoms and having a low threshold for pursing other additional diagnoses is reasonable.
Cerebrovascular Accident, Cervical Myelopathy, or Both?
Cerebrovascular accidents are a leading cause of morbidity and mortality in the United States. Many conditions exist which may mimic this disease process including seizures, migraines, metabolic derangements, infections, space-occupying lesions, neurodegenerative disorders, peripheral neuropathy, cervical myelopathy, syncope, other vascular disorders, and functional neurologic disorder. Timely diagnosis and treatment are important in order to preserve functional status in these patients. A 48-year-old male presented to the emergency department with a 28-hour history of worsening left sided numbness, tingling, weakness, and feeling off balance. The patient stated that for the past several months he had noticed these symptoms, but they suddenly became worse the day prior. He also described shooting pains down the left arm with certain movements of his neck. The patient denied any difficulty with speaking, understanding words, performing mental tasks, bowel or bladder incontinence, or right sided symptoms. Physical exam showed intact cranial nerves II-XII, 5/5 strength of upper and lower extremities on the right side, 4/5 strength of upper and lower extremities on the left side. Romberg test was normal, heel to shin and finger to nose were intact bilaterally. Foot drop was noted on the left side and placement of the foot on the ground was noted to be clumsy. Initial head CT in the emergency department showed a frontal lobe hypodensity and was without intracranial hemorrhage. Computed tomography angiography of the head and neck showed no large vessel thrombosis or stenosis. Echocardiography revealed normal chamber sizes, normal left ventricular ejection fraction, no patent foramen ovale, and no left atrial or left ventricular thrombus. Telemetry monitoring throughout the stay remained sinus rhythm. Magnetic resonance imaging of brain and cervical spine was performed showing multifocal acute infarcts of the right and left frontal lobes and severe cervical spondylosis at C4-C6 with spinal cord edema in T2 sequences slightly below that level. The patient subsequently underwent a cervical spine decompression for the spinal cord compression during the hospital stay. Due to the multifocal lesions noted on the brain MRI, a vasculitis workup was performed which returned negative for any abnormal test findings. The patient was also diagnosed with diabetes mellitus type 2 during the stay as he was found to have a glycosylated hemoglobin A1C of >12. He was initially hypertensive during hospitalization, but this resolved on its own after day three of the hospitalization so anti-hypertensives were not required. The patient was discharged home on high intensity statin therapy, dual oral hypoglycemic therapy for his diabetes mellitus, home physical therapy, and he was scheduled to start dual antiplatelet therapy seven days after cervical spine surgery. This dual antiplatelet therapy with clopidogrel and aspirin was to be continued for three weeks after which continuation with low dose aspirin was advised. As seen in this case, patients that present with a cerebrovascular accident should always be evaluated for other etiology behind his or her symptoms and having a low threshold for pursing other additional diagnoses is reasonable.