1.
脳血管障害.
他にpost-ictal (seizure) paralysis (Todds paralysis), Migraines (of the
complicated type), hypoglycemia, hyperglycemia, multiple
sclerosis
などがあげられる.
2.
救急のABCを評価し障害があれば対処する.
意識レベル,
神経学的所見を取り,
血液検査 (生化),
心電図, CXR,
頭部CT&
Strokeに対応できる体制がある病院でなければ,
十分な急性期治療は難しい.
3.
発症はいつか (どのくらい前か),
痛みがあるか,
前兆のようなものはあったか,
症状は発症後変化しているか.
以前に同様な発作があったか,
心疾患・高血圧の既往,
血液検査での異常,
糖尿病・高脂血症の既往.
Faculty Comments
Our goals from the history should be to
get information that allows us to prune down the differential, define a
possible lesion, which will influence our treatment plans. For example, a small
lacunar stroke indicates small vessel disease, usually the result of diabetes
and hypertension. This is best treated with anti-platelet agents like aspirin
and plavix to prevent future strokes. On the other hand, large strokes for the
most part indicate large vessel and heart disease (such as embolic events) and
are often treated with coumadin to prevent strokes in the future. The time of
onset is important since if it is less than 3 hours and there are no
contraindications, then the patient is a potential candidate for intravenous
tPA (tissue plasminogen activator).
To do this, we need information about the
course of the present illness, are symptoms getting better or worse? Was the
onset sudden? Was the onset associated with anything out of the ordinary, like
shaking, or a headache? We need to define the symptoms better, which side of
the face and arm, any other body involvement? We need to define the aphasia
better. In any neurologic patient, handedness is a key historical point
to indicate speech dominance.
4.
右手の運動障害と顔面の表情筋の麻痺があることと,
失語型がBroca失語であることから,
病巣は左側前頭葉の下前頭回～中前頭回と中心前回を含む比較的広い領域を含むものと思われる.これらの領域は中大脳動脈の支配領域である.
5.
Faculty Comments
Older
person who smokes, with
poorly control HTN, DM, heart disease (Atrial fibrillation
especially), and increased cholesterol, run a high risk for stroke.
Women who smoke and take Oral Contraceptives put themselves in a
hypercoaguable state. Smoking is always contraindicated! The risk of Oral
Contraceptives is even greater in women over age 35 who smoke and have a
migraine headache history.
In young people, strokes are more likely
to be secondary to a long list of really unusual neurologic diseases or to
another long list of things that makes them hypercoaguable. Although beyond the
scope of this case, one should be aware that young patients with strokes get
careful workups to determine the cause so treatment can be directed
appropriately.
6.
Faculty Comments
There is a 50% noncompliance rate
within 1 year. As the silent killer, hypertension rarely causes
symptoms. Remember that symptoms are the things a patient notices, signs
are things you notice or elicit. On top of the inherent problem of getting
patients to take a pill for no apparent reason, the pills have real and
unpleasant effects. Beta-blockers can cause fatigue, orthostatic hypotension,
and (most importantly) sexual dysfunction. Diuretics make the poor patient
urinate frequently. Even the latest wonder drugs, the ACE inhibitors, make some
people cough, make food taste bad (dysgusia), and angioedema in a few unlucky
patients. Many a patients first problem with hypertension is when they have a
stroke. Screening and patient education are crucial in preventing poor
outcomes due to hypertension.
7.
一過性脳虚血発作:
単一の脳血管灌流領域における局所神経症状を呈する短時間の発作で,
脳虚血以外の原因が考えにくいもの. 24時間未満に後遺症を残さず回復する.
症状:
内頸動脈系
