Tariq Shafi.
71-year-old man with background of epilepsy (for which he is on Phenytoin), ex-smoker (stopped age 45, he has a 25 pack-year history) and who consumes 42 units alcohol per week. He lives at home with his wife and is independent with daily activities (regularly plays golf). He had a DVT in 2016 for which he received anticoagulation. He has not had a seizure for many years. He had an admission at St Richard's from 24th April to 1st May 2019 with dysarthria, word-finding difficulty and left homonymous hemianopia. ECG showed sinus rhythm. MRI showed multifocal ischaemic lesions. Echo and Carotid Doppler were unremarkable. MRA neck showed no evidence of dissection within the Circle of Willis or arteries of the neck. Bloods were unremarkable except high cholesterol (total cholesterol 5.16, LDL 2.67). Vasculitis screen including ESR and ANCA were normal. He was commenced on Aspirin 300mg daily (changed to Clopidogrel 75mg daily after 14 days) and Atorvastatin 40mg nocte. He was told not to drive. He was admitted again to St Richard's (Lavant ward) on 14th July with right arm weakness, right facial droop and word-finding difficulties. Stroke bloods including ESR were unremarkable. BP on admission was 144/87. ECG showed sinus bradycardia (57/minute). He had slight loss of nasolabial fold on the right, visual inattention and past pointing on the right. Power was 5/5 in all limbs. Swallow was assessed and deemed safe. CT brain showed established right and left occipital infarcts. MRI brain on 16th July showed multiple new infarcts in the left MCA and left PCA territory and both cerebellar hemispheres. CT angiogram aortic arch and bilateral carotids showed proatlantal artery type 2 (external carotid artery and vertebral artery anastomosis) and very gracile vertebral arteries. Carotid Doppler and Echo were unremarkable. He improved clinically and was discharged from physio and OT. His case was discussed with the Vascular Surgeons and images reviewed and plan was for medical management. He was discharged and will be reviewed in Stroke clinic. 71-year-old man with background of epilepsy (for which he is on Phenytoin), ex-smoker (stopped age 45, he has a 25 pack-year history) and who consumes 42 units alcohol per week. He lives at home with his wife and is independent with daily activities (regularly plays golf). He had a DVT in 2016 for which he received anticoagulation. He has not had a seizure for many years. He had an admission at St Richard's from 24th April to 1st May 2019 with dysarthria, word-finding difficulty and left homonymous hemianopia. ECG showed sinus rhythm. MRI showed multifocal ischaemic lesions. Echo and Carotid Doppler were unremarkable. MRA neck showed no evidence of dissection within the Circle of Willis or arteries of the neck. Bloods were unremarkable except high cholesterol (total cholesterol 5.16, LDL 2.67). Vasculitis screen including ESR and ANCA were normal. He was commenced on Aspirin 300mg daily (changed to Clopidogrel 75mg daily after 14 days) and Atorvastatin 40mg nocte. He was told not to drive. He was admitted again to St Richard's (Lavant ward) on 14th July with right arm weakness, right facial droop and word-finding difficulties. Stroke bloods including ESR were unremarkable. BP on admission was 144/87. ECG showed sinus bradycardia (57/minute). He had slight loss of nasolabial fold on the right, visual inattention and past pointing on the right. Power was 5/5 in all limbs. Swallow was assessed and deemed safe. CT brain showed established right and left occipital infarcts. MRI brain on 16th July showed multiple new infarcts in the left MCA and left PCA territory and both cerebellar hemispheres. CT angiogram aortic arch and bilateral carotids showed proatlantal artery type 2 (external carotid artery and vertebral artery anastomosis) and very gracile vertebral arteries. Carotid Doppler and Echo were unremarkable. He improved clinically and was discharged from physio and OT. His case was discussed with the Vascular Surgeons and images reviewed and plan was for medical management. He was discharged and will be reviewed in Stroke clinic.
