Clinical Assessment — Sukh Lal, 32M

Working Diagnosis: Cardioembolic Ischemic Stroke (Left MCA territory)

🔍 Clinical Correlation

RHD-MR + AF = highest embolic risk among all valvular diseases. Digoxin use strongly implies the patient has AF, which is the most likely embolic source.

⚡ Immediate Management (Acute Phase)

• NIHSS scoring — quantify stroke severity
• IV access, cardiac monitoring (12-lead ECG — look for AF)
• SpO₂, BP, RBS, CBC, PT/INR (critical — patient may have been on anticoagulation or needs it)
• Urgent NCCT brain → rule out hemorrhage before any thrombolysis decision
• MRI brain + DWI (preferred) → confirm infarct, territory, size
• Echo (TTE/TEE) → LA thrombus, mitral valve morphology, LA size
• Carotid Doppler

• Window: ≤4.5 hours from symptom onset (if no contraindications)
• Key contraindications to check:
  • Recent anticoagulation (check INR — if >1.7, tPA is contraindicated)
  • Active bleeding, BP >185/110 mmHg (must control first)
  • History of prior ICH
• If eligible → Alteplase 0.9 mg/kg IV (max 90 mg; 10% as bolus, rest over 60 min)
• Mechanical thrombectomy if large vessel occlusion (LVO) on CT angiography, within 6–24 hr window

• Keep SBP <185/110 if thrombolyzing; <220/120 if not
• Avoid aggressive BP lowering in acute stroke (cerebral autoregulation is impaired)
• NBM initially (aspiration risk with aphasia/dysphagia) → NGT feeding if needed
• Avoid fever (antipyretics), hyperglycemia (insulin sliding scale — target 140–180 mg/dL)
• DVT prophylaxis: compression stockings; LMWH after 24–48 hr post-thrombolysis
• Head end elevation 30°

💊 Antithrombotic Strategy (Cardioembolic Stroke in RHD-MR)

NOAC (Rivaroxaban, Apixaban etc.) are contraindicated in rheumatic valvular AF — warfarin remains the gold standard (per ACC/AHA Valvular Heart Disease Guidelines).

🫀 Ongoing Cardiac Management

• Continue Digoxin (rate control in AF) — check levels, avoid toxicity
• Continue Pentid 400 (Penicillin V) — maintain ARF secondary prophylaxis religiously (WHO recommends lifelong or until age 40+ in RHD with carditis)
• Optimize heart failure if present (ACE inhibitor/ARB, diuretics for MR)
• Cardiology + Cardiothoracic surgery referral: assess need for mitral valve repair/replacement (MVR) — definitive treatment to reduce embolic risk long-term
• Serial ECG / Holter monitoring to document AF burden

🧠 Rehabilitation

• Speech therapy (aphasia rehabilitation — crucial)
• Physiotherapy — right-sided hemiparesis
• Occupational therapy — left UL weakness (note: bilateral involvement warrants re-evaluation of stroke territory vs. additional lesions)
• Neuropsychological assessment
• Dysphagia screening before oral feeds

⚠️ Key Points to Remember

1. Left UL weakness + right hemiparesis in the same patient — consider whether this is a bilateral or watershed stroke, or a large dominant hemisphere lesion affecting both motor pathways. Re-examine: is left UL weakness upper motor neuron pattern? Consider MRI urgently.
2. Chest pain preceding stroke — rule out acute MI with embolism, or PE, or aortic dissection (CT angiography if suspected).
3. At 32 years old with RHD, this patient likely needs mitral valve surgery in the future — embolism is a strong indication to expedite surgical evaluation.
4. INR must be checked before any antithrombotic decision — patient's current medication status matters.