A 60-year-old male presented with left-sided weakness and difficulty in speech

Dr. Iffat Islam Khan (MD Resident): A 60-year-old male presented with weakness of the left side of the body followed by a sudden fall on the ground while working in the field, with difficulty in speech for 03 months. Weakness was sudden in onset which involved left upper and lower limbs with the inability to move the left side of the body and difficulty in walking. The patient also noticed that there was a deviation of the face towards the right side associated with dribbling of food with difficulty in speech but can follow the command with difficulty. There was also urinary incontinence for the same duration, but the bowel movement was normal. There was no history of trauma to the head or spine, convulsion, headache, unconsciousness, vomiting, fever, and double vision. He has been suffering from multivessel coronary artery disease with significant bilateral carotid artery stenosis since 2018. The patient was advised for surgical revascularization with concurrent coronary artery bypass graft and carotid endarterectomy surgery, but he refused. Then he was managed conservatively, but he took his medication irregularly. The patient is hypertensive and has been treated with antihypertensive for the last 5 years. He mentioned having alcohol occasionally. He had no other chronic disease. General examinations revealed normal findings except his pale complexion with moderate anemia. Moreover, cardiovascular system examinations revealed pulse was 75 beats/min (regular), blood pressure 160/100 mmHg. A carotid bruit present over the both carotid area with the bell of the stethos -cope in a breath-hold position. Examinations of the nervous system revealed normal higher cerebral function; speech was sluggish, upper motor type left-sided facial nerve palsy. On the left upper and lower limb motor system examination, muscle bulk and power (medical research council grade2/5) were reduced, muscle tone was increased, and deep tendon reflexes were exaggerated as well as planter reflex was extensor. On musculoskeletal system examination, the patient was unable to walk, mild flexion deformity in the left elbow and wrist with restrictions on the movement partially flexed left foot, and external rotation of the left hip joint.

The patient was further investigated with hematological, biochemical, microbiological as well as radiological investigations (Table I). Hematological investigations demonstrated hemoglobin level (%) was 10.8 g/dL and erythrocyte sedimentation rate-55 mm in 1st hour. Biochemical investigations showed serum cholesterol-469 mg/dL, low density lipoprotein-271 mg/dL, as well as triglycerides-280 mg/ dL. Serum electrolytes, Serum creatinine, and random blood sugar were within normal limits. A computed tomography scan scan of the brain showed a hypodense area in the right thalamoganglionic region of the brain (Figure 1). Moreover, electrocardiogram had features of old myocardial infarction (MI) in II, III, aVF leads, and echocardiography showed left ventricular dysfunction (ejection fraction-40%) with regional wall motion abnormality. Duplex ultrasonogram of neck vessels showed 60% and 80% stenosis of the left and right internal carotid artery, respectively. Coronary angiography demonstrated triple vessel disease where 80% stenosis in the left anterior descending artery, 70% stenosis in the left circumflex artery, and 90% stenosis in the right coronary artery.
Based on history, proper physical examination, and adequate investigations, we would like to draw a provisional diagnosis.

Provisional Diagnosis
Ischemic stroke due to bilateral carotid artery stenosis with triple vessel disease

Differential Diagnosis
Intracranial space occupying lesion (ICSOL) Chronic subdural hematoma Dr. Mohammad Tariqul Islam: The term 'ICSOL' includes lesion which expands in volume to displace normal neural structures and lead to an increase in intracranial tension. This lesion causes irritation or destruction of brain tissue, such as focal seizures and paralysis, the feature of increase intracranial pressure and false localizing signs. 1, 2 A space-occupying lesion characterized by Persistent headache felt in the midline not due to any other detectable cause and unresponsive to simple medication. It may continuous and progressive, paroxysmal, aggravated by coughing, stooping forward, or changing posture. Associated symptoms of space-occupying lesion are vomiting, visual loss, motor and sensory defect, and personality disorder. In most of the cases presented with papilloedema, however, it depends upon the location and mass effect of ICSOL. 2, 3 Patients may also present with bradycardia, hypertension, irregular respirations, ipsilateral pupillary enlargement, and loss of light reflex due to compression of the 3rd cranial nerve. Computed tomography scan is capable of disclosing not only a tumor mass, its location, and extension but also any associated pathological changes such as brain edema around the mass, hydrocephalus, hemorrhage, cystic formation, calcification, etc. Magnetic resonance imaging allows a more detailed visualization than computed tomography scan. [2][3][4] Dr. Redoy Ranjan: A chronic subdural hematoma in an old clot of blood on the surface of the brain beneath its outer covering most often occurs in a patient with the age of 60 years and older having brain atrophy. 5 When the brain becomes atrophied inside the skull, even minor injury can cause tearing of blood vessels over the cerebrum which resulting in a slow accumulation of blood over several days to weeks. Other risk factors include alcoholism, seizures, excess cerebrospinal fluid drainage by shunts from the brain, and blood-thinning medications. 4, 5 The most common complaint is a headache, accompanied by lethargy, vomiting, memory loss, fluctuating level of confusion, impaired vision, and seizures. A chronic subdural hematoma may mimic many other brain diseases, including dementia, stroke, and temporary disruption of blood supply to a portion of the brain (TIA), encephalitis, and brain lesions such as trauma or abscess. Computed tomography scan shows hematomas are usually hypodense concavo-convex lesions. But isodense or mixed density lesions are also observed. Magnetic resonance imaging could help in making a diagnosis that is more sensitive than a computed tomography scan in determining the size and internal structures. Fresh bleeding, hemolysis, and hemoglobin changes can also be observed by magnetic resonance imaging. 1, 4-6

Dr. Khan's Diagnosis
Ischemic stroke with left-sided hemiplegia

Discussion
Dr. Islam: Stroke occurs when a blood vessel in the brain ruptures and bleeds or when there is a blockage in the blood supply to the brain. The rupture or blockage prevents blood and oxygen from reaching the brain tissue. 5, 6 Without oxygen, brain cells and tissue became damaged and begun to die within minutes. Stroke symptoms include paralysis, numbness or weakness in the face, arm, leg, especially one side of the body, slurring of speech, vision problem, and difficulty in walking, loss of balance and coordination, severe sudden headache. Stroke requires immediate medical attention; prompt patient management is the key to preventing brain damage, long term disabilities, and death. 3-5 Stroke is mainly categorized into 2 types; Ischemic stroke and hemorrhagic stroke. The two most common types of ischemic strokes arethrombotic and embolic. During an ischemic stroke, the artery supply blood to the brain become narrow and blocked. This blockage is caused by blood clots or reduction of blood flow due to thrombotic or embolic manifestations. The cause of stroke depends on the type of stroke. A Transient ischemic attack is caused by a temporary spasm in an artery to the brain and after a few minutes to a few hours,

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BSMMU J 2021; 14: 7-12 Prof. Asit Baran Adhikary: According to the World Health Organization, stroke ranks 3rd leading cause of death in Bangladesh, and the death rate due to stroke in Bangladesh is 84th in the world. The rate of disability from stroke is about 485 per 10,000 people. 6 Carotid artery stenosis is one of the strong leading causes of ischemic stroke. Carotid arteries supply the frontal 2/3rd of the brain. Atherosclerosis commonly affects carotid arteries and has shown a higher tendency to form in the bulb area. Strokes occur due to blockage at the level of the bulb of the internal carotid artery. 3-5, 9 Risk factors for carotid atherosclerosis are old age, obesity, smoking, hypertension, diabetes mellitus, sedentary lifestyle, and hypercholesterolemia. Carotid stenosis remains asymptomatic before it has caused a stroke. Less than 75% of asymptomatic carotid stenosis carries a 1.3% chance of stroke per year and 70% or greater symptomatic carotid stenosis carries an annual stroke risk of 10-15%. There are 3 stroke preventive options in carotid stenosis, which are carotid endarterectomy, carotid stenting, and conservative management with lifestyle modifications. In the management of carotid stenosis, a major concern is the possibility of having complications like perioperative stroke or death which is about 2.3% and 4.1% in CEA and carotid stenting, accordingly. 10-12 So, carotid endarterectomy is much safe and feasible. However, when an invasive procedure is contraindicated or undesirable for any reason, aggressive medical management with a statin and anti-platelet drug is the next option.   When a patient has a persisting major continuing impairment such as hemiplegic with disabilities the rehabilitation component of care is the main focus of management. The comprehensive rehabilitation management program is characterized by a holistic approach with a multidisciplinary team member. Firstly, reassurance and counseling are the keys to management. 16, 17 Pharmacological therapy, including symptomatic management, control of hypertension, and dyslipidemia should be done. Use of aspirin or clopidogrel as an antiplatelet agent, cerebral vasodilator, and others. In rehabilitation, management includes proper bed positioning, a therapeutic exercise in the form of passive range of motion exercise, left upper and lower limb stretching exercise, Achilles tendon stretching exercise, proprioceptive neuromuscular facilitation exercise of left facial muscle. all exercise should be done 10 repetitions 3 times daily. Therapeutic modalities are Infrared radiation for 20 minutes daily over the affected part of the body and Electrical stimulation therapy for 15 minutes per day ( Figure 2). Other therapies are speech therapy, cognitive therapy, occupation therapy, swallowing therapy, and bladder rehabilitation management program. Early diagnosis with immediate referral and multidisciplinary team management may prevent further progression of disabilities, complications, and minimize the impairments. 18-20 Dr. Ranjan: What is the role of electrical stimulation therapy to improve the muscle power of this patient?
Dr. Islam: Electrical stimulation stimulates the motor unit and causes muscle contractions. This helps in regaining the properties of muscle and boost Neuroplasticity after stroke by increasing the stimulation and send it to the brain. Electrical current is applied through electrodes to one or more targeted muscles. 12-15, 18 The muscle size, the position of the electrodes, and the amount of intervening tissue between muscle and skin dictate the intensity needed from the electrical stimulation unit to cause a contraction. Electrical stimulation therapy was given to this patient in the form of a faradic current. A frequency usually ranges between 10-100Hzs. Prof. Adhikary: Carotid endarterectomy is thought to reserve cognitive impairment in patients with highgrade internal carotid artery stenosis by reversing cerebral perfusion. Carotid endarterectomy is effective for symptomatic patients with 70-99% stenosis and age between 40-70 years. Which was absolutely indicated for this patient. Accepted practice in many centers is to wait 4-6 weeks after the onset of deficit before proceeding with carotid endarterectomy. It is due to the fear that early revascularization will increase the size of the infracts. The infrared radiation treatment produces a heating effect in the superficial epidermis and dermis that causes vasodilatation which increases blood circulation. This provides oxygen supply and nutrition supply in that area leading to drain waste products that relieve pain. Mild heating by infrared radiation causes relaxation of the muscle and thus relieving muscle spasm. Relief of pain also includes relaxation in the muscles and helps to relieve muscle spasms associated with injury and inflammation . 23-

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Prof. Adhikary: Treatment of ischemic stroke needs multi-disciplinary team involvement, which is often missed by the patients and sometimes from doctors also. That can linger treatment cost, a disability could get worsen. Timely referral with proper counseling is needed. To summarize, this was a case of ischemic stroke due to carotid stenosis with multivessel coronary artery disease. Although this patient was initially referred for concurrent carotid endarterectomy and coronary artery bypass graft, the attendant and patient refused to do it, and later admitted with progressive atherosclerosis involving multiple vascular system and associated complications. A simple deviation of the path can cause major damage as we can see in this case. Ideal options for this case are to treat with either concurrent or staged carotid intervention and coronary artery bypass graft surgery which is concordance to other published articles. 10, 22, 25-28

Final Diagnosis
Ischemic stroke with left-sided hemiplegia