Ep 169: A 65-Year-Old with Right-Sided Weakness

This episode is a discussion with Harrison’s editor, Dr. Andrew Josephson, about the treatment of stroke.

Read more on this topic in Harrison's.

Harrison's Principles of Internal Medicine, 22nd Edition

Transcript

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[Ms. Heidhausen] This is Katerina Heidhausen, executive editor of Harrison's Principles of Internal Medicine. Harrison's Podclass is brought to you by McGraw Hill's AccessMedicine, the online medical resource that delivers the latest content from the best minds in medicine. And now, on to the episode. 

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[Dr. Handy] Hi, everyone. Welcome back to Harrison's Podclass. We're your co-hosts. I'm Dr. Cathy Handy. 

[Dr. Wiener] And I'm Dr. Charlie Wiener, and we're joining you from the John Hopkins School of Medicine. 

[Dr. Handy] Welcome to today's episode, a 65-year-old with right-sided weakness. 

[Dr. Wiener] Cathy, today's episode is special as we are welcoming one of the Harrison's editors to discuss our case. 

[Dr. Handy] Great. Why don't we start with the case and the question? 

[Dr. Wiener] Okay. So your patient today is a 65-year-old man with a longstanding history of coronary artery disease, hypertension, hyperlipidemia, and type 2 diabetes. Four years ago, he had an LAD stent placed after he presented with unstable angina, but he has done well since. He works as an engineer in a large metropolitan hospital. He quit smoking 30 years ago and does not consume alcohol or illicit drugs. He tries to walk one to two miles at least twice a week. His medications are amlodipine, losartan, metformin, and atorvastatin. He follows up regularly with his PCP, and his last hemoglobin A1c was 6%. 

[Dr. Handy] Sounds like he's been doing pretty well overall. 

[Dr. Wiener] Yeah, he has been until today. While at work, meeting with colleagues, over 10 to 15 minutes, he develops a right-sided facial droop, drops his pen because of right arm and hand weakness, and when he tries to stand up, his right leg collapses. When asked by his colleagues what is happening, he garbles unintelligibly. 

[Dr. Handy] First on my list, it sounds like he's having a stroke. 

[Dr. Wiener] That's what is going on. His colleagues actually recognize it, and his hospital had just run a major public awareness campaign focusing on FAST or the FAST approach for stroke awareness. 

[Dr. Handy] Just to go over that, FAST is the acronym that highlights common symptoms and emphasizes that time is important. It stands for facial weakness, arm weakness, speech abnormality, and time. 

[Dr. Wiener] Because his colleagues recognized this, they called a rapid response team, and he was transported immediately to the emergency department. He arrived there in less than one hour after symptoms onset. In the ED, on physical examination, he is afebrile. His blood pressure is 150/90, heart rate 90 per minute, respirations 12, with an oxygen saturation 98% on nasal oxygen. He does not seem to be in distress, but has definite right facial weakness, right hemiplegia, and notable dysarthria with aphasia. He immediately gets a dry CT scan, which shows no sign of hemorrhage. And that gets us to our question, which is asking, which of the following intravenous interventions is immediately indicated? And the options are: A. esmolol; B. heparin; C. insulin; D. mannitol; E. tPA or tissue plasminogen activator. 

[Dr. Handy] We're honored today to have one of the Harrison's editors, Dr. Andrew Josephson, as our guest discussant today. He's the chair of neurology at University of California at San Francisco, and he's here today to help us answer this question. So welcome to the podcast. 

[Dr. Josephson] Hey, thanks for having me. 

[Dr. Wiener] So Dr. Josephson, the question asks about treatment, but let's start with the basics. Can you talk a bit about the epidemiology of stroke, in particular, ischemic stroke? 

[Dr. Josephson] Sure. Well, stroke overall is the second leading cause of death worldwide. In the United States, nearly 7 million Americans over the age of 20 report having a stroke. And this prevalence is expected to go up by around 3.4 million adults in the next decade, representing somewhere in the neighborhood of 4% of the entire population. When we think about stroke, about three-quarters of stroke is ischemic, one quarter is hemorrhagic. And in this case, the CT scan that is done acutely is meant to exclude the patients who had hemorrhage. And therefore, this is a case of ischemic stroke. 

[Dr. Handy] And what about the common symptoms? We talked in this case presented here about the FAST acronym. Can you tell us more? 

[Dr. Josephson] Well, it's a great way for the public to remember things to look for: speech problems, arm weakness, facial weakness, but I think we all know as neurologists and internal medicine physicians that stroke can present in different ways: weakness or numbness in one limb, dizziness, acute onset headache, difficulty with gait and ataxia, any of those symptoms or a combination thereof, in addition to others, can represent acute ischemic stroke. 

[Dr. Wiener] So let's get back to the question, Dr. Josephson. It's asking about treatment. Which one of the ones listed, what is the right answer to the question? Which is immediately indicated? 

[Dr. Josephson] Well, of these options, I think the right answer is E. tissue plasminogen activator or alteplase. There are currently two approved therapies for thrombolysis in ischemic stroke: tissue plasminogen activator or TNK, tenecteplase. And increasingly, hospitals are turning towards the latter for a variety of reasons we don't have to get into. There are windows of time in which these therapies are effective and safe. And outside of those windows, they're either no longer effective or no longer safe. And generally, in the United States, we use a four-and-a-half-hour window from the last time the patient was seen normal to provide eligibility to get one of these thrombolytic therapies. And in this case, the patient got to the hospital quickly. The CT scan was appropriately done. I'm sure a checklist went by to make sure there weren't any contraindications like a bleeding diathesis or on anticoagulation. And if all of that lined up, the patient should get tPA and should get it quickly. 

[Dr. Handy] Not mentioned here are endovascular interventions. Can you tell us where we are in 2025 with those for the treatment of stroke? 

[Dr. Josephson] So we're about a decade into a real revolution in stroke care. So in addition to a CT scan, most people also will get at the same time, when they're being evaluated for an ischemic stroke, a CT angiogram. And what we're looking for is an LVO or a large vessel occlusion, a clot in the proximal middle cerebral artery or the basilar artery, for instance. And if that occurs, those patients should also go to the cath lab and get a mechanical thrombectomy, get a clot extraction. Now they can get tPA first and then get the clot extraction. And there are different windows for thrombectomy. Those windows extend certainly within six hours, but even between six and 24 hours of the last time the person was seen well, we use perfusion-based imaging to decide whether those patients should also get a thrombectomy to help their outcome. 

[Dr. Wiener] And talk a little bit about outcomes. What could be expected of me? What can we tell this patient's family in the ER, you think? 

[Dr. Josephson] Well, I think it's tricky because it depends on the type of stroke and the size of stroke and whether there ends up being a large vessel occlusion, but both thrombolysis and thrombectomy have been shown to certainly help people's morbidity. The goal is at 90 days to try to get a higher percentage of patients who are essentially normal, who are able to do all of their activities of daily living. And I think we can say with great certainty that if they were to get either of these therapies or a combination of those therapies, we will increase the chances that they will be able to do that. This is a therapy that you want, if you are eligible for it. It doesn't save lives. It doesn't hurt lives. It probably doesn't affect mortality; but the morbidity after a stroke, the weakness, the disability, the inability to do our activities of daily living are what we're all concerned about. And these are therapies that can certainly help increase the chances of somebody making a nice recovery. 

[Dr. Wiener] That's fantastic. Any other thoughts before we close, Dr. Josephson? 

[Dr. Josephson] I just think that the FAST acronym is but one example of what we need to continue to do to educate the public that when they have a patient who is exhibiting these signs, a friend, a loved one, call 911, because time is brain, time matters. The faster these individuals can get evaluated and then get treatment, the better. 

[Dr. Handy] Thank you so much. And thank you for joining us today. You can find this question and other questions like it in Harrison's Self-Review. And for our listeners, you can read more in the Harrison's chapter on stroke. Visit the show notes for links to helpful resources, including related chapters and review questions from Harrison's, available exclusively on AccessMedicine. If you enjoyed this episode, please leave us a review, so we can reach more listeners just like you. Thanks so much for listening. 

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