CASE REPORT

SENIOR CLINICAL CLERKSHIP Period of August 02nd 30th , 2010

HEMPLEGIA SINISTRA FLACCID + PARESE N. VII SINISTRA SENTRAL + PARESE N. XII SINISTRA SENTRAL

Atika Akbari, S. Ked (04094705051) Frizky Arlind, S.Ked (04094705118)

Advisor

: Dr. H. A. Rachman Toyo, SpS(K)

DEPARTMENT OF NEUROLOGY FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH PALEMBANG 2010

ENDORSEMENT PAGE

Case Report

Hemplegia sinistra flaccid + parese n. VII sinistra sentral + parese n. XII sinistra sentral

Presented by: Atika Akbari, S. Ked (04094705051) Frizky Arlind, S.Ked (04094705118)

Has been accepted as one of requirements in undergoing senior clinical clerkship period of August 2nd 30th 2010 in Department of Neurology Faculty of Medicine Sriwijaya University / RSMH Palembang.

Palembang, August 2010 Advisor

Dr. H. A. Rachman Toyo, SpS(K)

NEUROLOGY MEDICAL RECORD

I. Identification

Name Age Sex Address Religion Admission date

: Mr. S : 64 years : Male : Jl. Taman No. 165, Mariana, Banyuasin : Islam : August 2nd, 2010

II. Anamnesis The patient was admitted to Neurology ward RSMH because of the weakness on left arm and lower limb which happened suddenly. + 4 days before admitted to the hospital, when the patient wake up, suddenly he felt weakness on his his left arm and lower limb without unconsciousness. At that time, he didnt get headache, nausea and vomit, without stiffness, and without disturbance of sensibility on the left side. The weakness between left arm and lower limb was felt same. The patient can't move left arm and lower limb was felt same at all. The patient uses right hand to work. He could express his mind by talking, writing and giving sign. The patient understood other peoples mind which was expressed by talking, writing and giving sign. When he talking, his mouth deviate to left, and pelo. He had no complaining about urination and defecation. Then, the patient go to RS Kundur and hospitalized, he was given 4 medicines (the patient forgot their names and forms) and 1 injection medicine citicholin. Because there is no improvement, the patient send to RSMH Palembang. There are no history of getting headache oftenly, history of getting lesion in the eksternal genital which was painless and self healing, skin lesion which was painless, self healing, and his wife no history of abortion in > 16 weeks. There's no history diabetes mellitus. This illness was the first time for him.

III. Physical Examination PRESENT STATE Internal State Sense Nutrition Pulse Respiratory rate Blood pressure Temperature : compos mentis : sufficient : 100 beats/min : 22 times/min : 180/100 mmHg : 38,70C Lungs Liver Spleen Extremities Genital : no abnormality : no abnormality : no abnormality : see neurological state : no abnormality

Psychiatric state Attention Attention : cooperative : normal

Facial Expression Psyche contact

: natural : natural

Neurological state Head Shape Size Symetric Hematome Tumor : brachiocephaly : normal : yes : no : no Deformity Fracture Fracture pain Vessel Pulsation : no : no : no : no widening : no disorder

Neck Position Torticolis : straight : no

Deformity Tumor Vessels

: no : no : no widening

Nape of neck stiffness : no

CRANIAL NERVES Olfaktorius nerve Smelling Anosmia Hyposmia Parosmia Right No disorder No No No Left No disorder No No No 4

Opticus nerve Visual acuity Campus visi

Right 6/6 PH (-) V.O.D

Left 6/6 PH (-) V.O.S

Anopsia Hemianopsia

No No

No No

Oculi fundus Edema papil Atrophy papil Retina bleeding No No No No No No

Occulomotorius, and Abducens nerves Diplopia Eyes gap Ptosis Eyes position Strabismus Exophtalmus Enophtalmus

Trochlearis Right No No No Left No No No

No No No No no abnormality

No No No No no abnormality

Deviation conjugae

Eyes movement Pupil Shape Size Isochor/anisochor Midriasis/miosis

Round 3mm isochor No

Round 3mm isochor No

Light reflex direct + + 5

consensuil accommodation

+ + No

+ + No

Argyl Robertson

Trigeminus nerve Motoric Biting Trismus Corneal reflex Right No disorder No Yes Left No disorder No Yes

Sensory Forehead Cheek Chin Normal Normal Normal Normal Normal Normal

Facialis nerve Motoric Frowning Eyes closing Giggling Nasolabial fold Facial shape rest Speaking/whistling No disorder No disorder No disorder No disorder Right simetric Normal Normal Normal Left simetric Normal angle paralysis flat

Sensory 2/3 anterior tounge No disorder No disorder

Autonomy Salivation Lacrimation Chvosteks sign No disorder No disorder No disorder No disorder No disorder No disorder

Statoacusticus nerve Cochlearis nerve Right Left 6

Whispering Hour ticking Weber test Rinne test Vestibularis nerve Nystagmus Vertigo

No disorder No disorder Normal Normal

No disorder No disorder Normal Normal

No No

No No

Glossopharingeus and Vagus nerves Pharyngeal arch Uvula Swallowing disorder Hoarsing/nasalising Heart beat Reflex Vomiting Coughing Occulocardiac Caroticus sinus No disorder No disorder No disorder No disorder No disorder No disorder No disorder No disorder Right No disorder No disorder No No Normal Left No disorder No disorder No No Normal

Sensory 1/3 posterior tounge No disorder No disorder

Accessorius Nerve Shoulder Raising Head Twisting

Right No disorder No disorder

Left No disorder No disorder

Hypoglossus Nerve Tounge Showing Fasciculation Papil Athrophy

Right No deviation no no

Left deviation no no

Dysarthria

yes

yes

MOTORIC ARM Motion Power Tones Physiological Reflex Biceps Triceps Radius Ulna Normal Normal Normal Normal Decrease Decrease Decrease Decrease Right Enough 5 Normal Left Less 0 Decrease

Pathological Reflex Hoffman Tromner Leri Meyer Trofik None None None None None None None None

LEG Motion Power Tones Clonus Tigh Foot

Right Enough 5 Normal

Left Less 0 Decrease

Negative Negative

Negative Negative

Physiological reflex KPR APR Normal Normal Decrease Decrease

Pathological reflex Babinsky Chaddock Oppenheim Negative Negative Negative Negative Negative

Gordon Schaeffer Rossolimo Mendel Bechterew

Negative Negative Negative Negative Negative

Negative Negative Negative Negative

Abdominal skin reflex Upper Middle Lower Tropik

Negative Negative Negative Negative Negative Negative Negative Negative

SENSORY No abnormality.

PICTURE

VEGETATIVE FUNCTION Micturition Defecation : no abnormality. : no abnormality.

MENINGEAL SIGNS Right Nape of neck stiffness Kerniq Lasseque Brudzinsky Neck Cheek Symphisis Leg I Leg II Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Left Negative Negative Negative

GAIT, BALANCE, AND COORDINATION Cant be examined Gait Ataxia Hemiplegiac Scissor Propulsion Histeric Limping Steppage Astasia-Abasia : not confirmed : not confirmed : not confirmed : not confirmed : not confirmed : not confirmed : not confirmed : not confirmed Equilibirium and Coordination Romberg Dysmetri finger finger finger nose heel - heel : not confirmed : not confirmed : normal : normal : not confirmed

Reboundphenomenon: not confirmed Dysdiadochokinesis : not confirmed Trunk Ataxia Limb Ataxia : not confirmed : not confirmed

MOTION ABNORMAL Tremor Chorea : no : no 10

Athetosis Ballismus Dystoni Myoclonus

: no : no : no : no

LIMBIC FUNCTION Motoric aphasia Sensoric aphasia Apraksia Agraphia Alexia Nominal aphasia : no : no : no : no : no : no

ABNORMAL MOVEMENT No abnormality.

VERTEBRAL COLUMN Kyphosis Lordosis Gibbus Deformity : no : no : no : no Tumor Meningocele Hematome Tenderness : no : no : no : no

IV. LABORATORY FINDINGS

BLOOD (2 Agustus 2010) Hb Ht Leukosit LED Trombosit Dc Bss Cholestrol total : 14,2 g/dl : 44 : 5700/mm3 : 10/mm3 : 219.000 : 0 / 2 / 2 / 69 / 22 / 5 : 116 mg/dl : 284 mg/dl ( < 200 ) 11 ( 14 18 ) ( 40 - 48 ) ( 5000 - 10.000 ) ( < 10 ) ( 200.000 500.000 )

HDL LDL Trigliserida SGOT SGPT Asam Urat Ureum Kreatin Protein total Albumin Globulin Na K Ca

: 52 mg/dl : 206 mg/dl : 151 mg/dl : 33 /l : 26 /l : 4,5 mg/dl : 31 mg/dl : 1,3 mg/dl : 7,4 mg/dl : 4,7 mg/dl : 2,7 mg/dl : 140 mmol/l : 3,5 mmol/l : 2,45 mmol/l

( < 55 ) ( < 130 ) ( < 150 ) ( < 40 ) ( < 41 ) ( 3,5 7,1 ) ( 15 39 ) ( 0,9 1,3 ) ( 6,0 7,8 ) ( 3,0 5,0 ) ( 136 155 ) ( 3,5 5,5 ) ( 2,02 2,60 )

3 Agustus 2010 Protrombin plasma APTT Fibrinogen eFibrinogen CPT CAPT INR : 13,64 seconds (12-18) : 29,50 seconds (25-35) : 607 mg/dl : 390 mg/dl : 13,9 seconds : 38,8 seconds : 0,87

URINE (7 Agustus 2010) Epithel Leucocyte Eritocyte :+ : 0-2 /HPF : 0-1 /HPF Protein Glucose : trace :-

Sylinder/crystal : -

Rongen Thorax

: normal thorax

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V. DIAGNOSIS Clinical Diagnosis : Hemplegia sinistra flaksid + parese n. VII sinistra sentral + parese n. XII sinistra sentral Topical Diagnosis : Lacunar cerebral infarct capsula interna Etiological Diagnosis : Trombosis, serebri

VI. MANAGEMENT Medicine :

-IVFD RL gtt xx/M - citicholine 2x250 mg IV - captopril 2x25mg tab - simvastatin 1x10 mg tab - paracetamol 3x500mg PRN - aspilet 1x80 mg tab - diet porridge low salt Pro CT scan head Fisioterapi: - Bed positioning - Infra Red Radiation left side extremity - Bobath therapy

VII. PROGNOSIS Quo ad vitam Quo ad functionam : bonam : dubia ad bonam

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CASE ANALYSIS

Topical diagnosis

1. Lession in cortex hemisferium cerebri dextra, the symptoms: - Motoric deficit (hemiparese sinistra) - Iritatif symptom (kejang pada sisi kiri) - Focal symptom (The paralysis is not same ) - Sensoric deficit on the paralysis side

The symptoms found in the patient:

- Hemiplegia sinistra flaccid - No Seizures on the paralysis side - The paralysis of left arms and left lower limb are same - No sensibility disorder on the left side body

So, the possibility of lession in cortex cerebri hemisferium dextra can be excluded. 2. Lession in subcortex hemisferium cerebri dextra, the symptoms: - Motoric deficit (hemiparese sinistra) - Motoric aphasia - Hemiplegia sinistra flaccid - No pure motoric aphasia The symptoms found in the patient:

So. the possibility of lession in subcortex cerebri hemisferium dextra can be excluded.

3. Lession in capsula interna hemisferium dextra, the symptoms: - Hemiparese/hemiplegi typica - Parese n.VII sinistra central - Parese n.XII sinistra central The weakness in the paralysis side is same

The symptoms found in the patient:

- Hemiplegi sinistra flaccid - Parese n.VII sinistra central - Parese n.XII sinistra central - The weakness in the paralysis side is same

So, the possibilityof lession in capsula interna hemisferium dextra can be made.

There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation 14

infarct (PACI), posterior circulation infarct (POCI), or lacunar infarct (LACI). These four entities predict the extent of the stroke, the area of the brain affected, the underlying cause, and the prognosis. A Total Anterior Circulation Infarct (TACI) is a type of cerebral infarction affecting the entire anterior circulation supplying one side of the brain. Total Anterior Circulation Stroke Syndrome (TACS) refers to the symptoms of a patient who clinically appears to have suffered from a total anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis. It is diagnosed when it causes all 3 of the following symptoms: The symptoms found in the patient:

Higher disfunction
o o o

Dysphasia Visuospatial disturbances Decreased level of consciousness

No No No

Homonymous hemianopia Motor and Sensory Defects (2/3 of face, arm, leg)

No No sensory defects

So, the possibility of a total anterior circulation infarct (TACI) can be excluded.

Partial Anterior Circulation Infarct (PACI) is a type of cerebral infarction affecting part of the anterior circulation supplying one side of the brain. Partial Anterior Circulation Stroke Syndrome (PACS) refers to the symptoms of a patient who clinically appears to have suffered from a partial anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis. It is diagnosed by any one of the following: The symptoms found in the patient:

2 out of 3 features of
o

Higher dysfunction

Dysphasia Visulospatial disturbances

No No No

Homonymous hemianopia

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Motor and Sensory Defects (>2/3 of face, arm, leg)

No sensory defects

Higher dysfunction alone Partial Motor or Sensory Defect

No No

So, the possibility of a partial anterior circulation infarct (PACI) can be excluded. A Posterior Circulation Infarct (POCI) is a type of cerebral infarction affecting the posterior circulation supplying one side of the brain. Posterior Circulation Stroke Syndrome (POCS) refers to the symptoms of a patient who clinically appears to have suffered from a posterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to confirm the diagnosis. It can cause the following symptoms: The symptoms found in the patient: Cranial nerve palsy AND contralateral Just contralateral motor defect motor/sensory defect Bilateral motor or sensory defect Eye movement problems (e.g.nystagmus) Cerebellar dysfunction Isolated homonymous hemianopia It has also been associated with deafness. No No No No No

So, the possibility of a posterior anterior circulation infarct (POCI) can be excluded.

Lacunar stroke or lacunar infarct (LACI) is a type of stroke that results from occlusion of one of the penetrating arteries that provides blood to the brain's deep structures. Patients who present with symptoms of a lacunar stroke, but who have not yet had diagnostic imaging performed may be described as suffering from Lacunar Stroke Syndrome (LACS). Clinical findings in patients medical record No visual deficit No noble disorders No brain stem function disorders

Lacunar cerebral infarct No visual deficit No noble disorders No brain stem function disorders Maximal deficit on one branch small artery

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Clinical features: Pure motor stroke (PMS) hemiparesis or hemiplegia that Hemiplegia typica

typically affects the face, arm, or leg of one side. Dysarthria, dysphagia, and transient Dysathria and dysphagia sensory symptoms. Pure sensory stroke (PSS) Marked by persistent or transient numbness, No tingling, pain, burning, or another unpleasant sensation on one side of the body. Ataksik hemipareses It displays a combination of cerebellar and Can't examined yet. motor symptoms, including weakness and clumsiness, on the ipsilateral side of the body. It usually affects the leg more than it does the arm; hence, it is known also as homolateral ataxia and crural paresis. The onset of

symptoms is often over hours or days. So, the possibility of a lacunar infarct (LACI) can be made, with location at posterior limb of the internal capsule.

Conclusion: Topical diagnosis : LACI capsula interna hemisferium dextra

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Etiological diagnosis Siriraj Stroke Score: SJ : (2,5 x level of consciousness) + ( 2 x Vomity) + ( 2 x Headache) + (0,1 x diastolic blood pressure) (3 x atheroma marker) 12 : (2,5 x 0 ) + ( 2 x 0) + (2 x 0) + (0,1 x 100) (3 x 1) 12 : 0 + 0 + 0 + 10 3 12 :-5 Conclusion : Non hemorragic cerebri

Differential Diagnosis Etiology: 1. Hemmoragic cerebri 2. Emboli cerebri 3. Trombosis cerebri

1. Hemmoragic cerebri, the symptoms: - Unconciusness > 30 minutes - Hemiparese kontralateral sentral So, etiology hemmoragic cerebri can be exluded.

Pada penderita ditemukan gejala: No No

Emboli cerebri, the symptoms: - Unconsciousness < 30 minutes - Arterial fibrilasi So, etiology emboli cerebri can be exluded.

The symptoms found in the patient: No No

Trombosis cerebri, the symptoms: - No unconsciousness So, etiology trombosis cerebri can be made.

The symptoms found in the patient: - No unconsciousness

Conclusion: Etiological Diagnosis: Trombosis cerebri

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REFERENCES 1. Guidelines Stroke 2004. Seri Ketiga. Kelompok Studi Serebrovaskuler PERHIMPUNAN DOKTER SPESIALIS DOKTER SPESIALIS SARAF INDONESIA PERDOSSI. 2. Stroke, Ischemic. Joseph U Becker, Charles R Wira, and Jeffrey L Arnold. 2010. 3. STROKE. Misbach, J. Fakultas Kedokteran Indonesia.

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