American Journal of Emergency Medicine 33 (2015) 477.e3–477.e4
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Simultaneous event of brachial artery occlusion and acute embolic stroke☆,☆☆ Abstract Although the rapid and accurate diagnosis of both acute ischemic stroke and extremity ischemia is essential to the timely and appropriate treatment, it is not always easy to differentiate between true stroke and stroke mimics. Although in general, limb ischemia due to extremity embolism is not included in stroke mimics or misdiagnosis, limb arterial embolism should be considered in the differential diagnosis of acute monoparesis because the diagnosis may be missed if the other typical manifestations of this presentation (pain, pallor, pulselessness, sensory loss, and coolness of the arm) are overlooked. Therefore, it is important to ensure that important signs are not missed whether the evaluation of the patient is done at the bedside. We report a case of a male patient presented to an emergency department with acute right upper extremity pain with headache, gait disturbance, and confused mentality. He was diagnosed by simultaneous brachial artery occlusion and acute stroke, which resulted in emergency surgical embolectomy and anticoagulation therapy. Rapid and accurate diagnosis of ischemic stroke is essential for timely and appropriate treatment with thrombolytic therapy. However, it is not always easy to differentiate between true stroke and stroke mimics. Patients who present with acute stroke mimics (ie, disorders that resemble stroke such as seizure, hypoglycemia, and psychogenic disorder) are incorrectly treated with thrombolytic therapy occasionally. Although, in general, limb ischemia due to extremity embolism is not included in stroke mimics or misdiagnosis [1,2], limb arterial embolism should be considered in the differential diagnosis of acute monoparesis because the diagnosis may be missed if the other typical manifestations of this presentation (pain, pallor, pulselessness, sensory loss, and coolness of the arm) are overlooked. We report a case of a male patient presented to an emergency department (ED) with acute right upper extremity pain with headache, gait disturbance, and confused mentality. He was diagnosed by simultaneous brachial artery occlusion and acute stroke, which resulted in emergency surgical embolectomy and anticoagulation therapy. A 73-year-old man presented to an ED with acute onset of right upper extremity pain, weakness, headache, gait disturbance, and confused mentality that had begun 5 hours ago. His medical history included hypertension, congestive heart failure, and ischemic heart disease. He has taken the β-blocker, diuretics, 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, and antiplatelet agent. The emergency physician diagnosed acute stroke and requested a neurologic consultation. The patient's blood pressure was 150/90 mm Hg, and a rhythm strip
☆ Conflicts of interest: None of the authors has any conflicts of interest to declare. ☆☆ Funding source: None of the authors has any funding source to declare.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
demonstrated atrial fibrillation rhythm at 88 beats per minute. Although he presented the right upper extremity weakness, the weakness of strength was not found on neurologic examination. Findings from the remainder of the neurologic examination, including speech and language, cranial nerves, coordination, right lower extremity strength, sensation, and reflexes and plantar responses, were normal. A computed tomographic (CT) scan of the brain showed no intracranial lesion except tissue loss due to old infarction in left frontal and right temporal lobes (Figure A). A magnetic resonance imaging and magnetic resonance angiography scan was performed to evaluate the confused mentality and subjective right upper arm weakness and showed acute infarction in right insula and temporoparietal lobes (Figure B). Because pain was a prominent feature of the presentation, the emergency physician checked a palpation of the right upper extremity for pulses. The right brachial and radial pulses were not palpable, and the right upper extremity was colder than the left upper extremity. An emergency right upper extremity enhanced CT was performed, which revealed a right brachial artery occlusion (Figure C and D). Intravenous heparin treatment was started, and the patient was transferred to the operating room for emergency right upper extremity exploration and embolectomy of the right brachial artery. A transthoracic echocardiogram performed for an intracardiac thrombus after the emergency operation was negative except small atrial septal defect with left to right shunt. He was transferred to department of neurology and treated for stroke accompanied by a right brachial artery occlusion. The patient recovered and was discharged home 13 days later with warfarin therapy. This patient illustrates that brachial artery occlusion can be occurred with stroke simultaneously. A brachial artery occlusion should be also considered in the differential diagnosis of paresis of the arm. The diagnosis may be missed if the typical manifestations of this presentation are overlooked. Age, female sex, atrial fibrillation, hypertension, diabetes, myocardial infarction, heart failure, and stroke are most common risk factors for thromboembolectomy of the upper limb [3]. Embolism from the heart is the major cause of upper limb ischemia. A Danish validation study of 1377 upper limb thromboembolectomies showed that 62.7% of patients had AF before or at the time of the admission for thromboembolectomy [4]. Upper limb thromboembolism is not as common as that of the lower limb. Lower limbs are approximately 4 times more commonly affected [5,6]. Symptoms of upper extremity arterial occlusion generally consist of pain, pallor, and sensory change as well as a loss of ulnar or radial pulses. Current treatment recommendations include immediate anticoagulation with heparin, surgical embolectomy, or intra-arterial thrombolytics and embolization. In systemic review article, operative management in acute upper limb ischemia was the most commonly used (86%), and an overall success rate of embolectomy showed 85% to 90% [7].
477.e4
S.H. Lee et al. / American Journal of Emergency Medicine 33 (2015) 477.e3–477.e4
Figure. a, The CT scans of a patient demonstrating no intracranial lesion except tissue loss by old infarction in left frontal and right temporal lobes. b, The diffusion-weighted magnetic resonance imaging scans of a patient showing acute infarction in right temporoparietal lobes. Three-dimensional reconstruction image of contrast-enhanced upper extremity CT demonstrating right brachial artery occlusion (c) and axial image of contrast-enhanced upper extremity CT demonstrating right brachial artery occlusion (arrow) (d).
Regardless of management, prompt treatment is warranted because upper extremity ischemia can lead to permanent loss of function. In this patient, a failure to recognize the brachial artery embolus could have resulted in further limb ischemia, gangrene, amputation, or death. Although the rapid identification of acute ischemic stroke is essential to the timely delivery of thrombolytics, careful and thorough examination with a complete history must be performed before specific treatment. Our case not only represents a rare simultaneous event of stroke and brachial artery occlusion but also emphasizes the importance of fundamental history taking and physical examinations in the evaluation of patients. Soo Hoon Lee, MD Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Republic of Korea Corresponding author. Department of Emergency Medicine Gyeongsang National University Hospital, Gangnam-ro 79 Jinju, Gyeongsangnam-do, Republic of Korea, 660-702 Tel.: + 82 55 750 8975; fax: +82 55 757 0514 E-mail address: [email protected] Nack-Cheon Choi, MD, PhD Department of Neurology, Gyeongsang National University Hospital Jinju, Gyeongsangnam-do, Republic of Korea In Seok Jang, MD, PhD Department of Thoracic Cardiovascular Surgery, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Republic of Korea
Tae-Sin Kang, MD Changwoo Kang, MD Jin Hee Jeong, MD Dong Seob Kim, MD Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do Republic of Korea http://dx.doi.org/10.1016/j.ajem.2014.08.049 References [1] Nor AM, Ford GA. Misdiagnosis of stroke. Expert Rev Neurother 2007;7(8): 989–1001. [2] Hand PJ, Kwan J, Lindley RI, et al. Distinguishing between stroke and mimic at the bedside: the brain attack study. Stroke 2006;37(3):769–75. [3] Andersen LV, Lip GY, Lindholt JS, et al. Upper limb arterial thromboembolism: a systematic review on incidence, risk factors, and prognosis, including a meta-analysis of risk-modifying drugs. J Thromb Haemost 2013;11(5): 836–44. [4] Andersen LV, Mortensen LS, Lindholt JS, et al. Upper-limb thrombo-embolectomy: national cohort study in Denmark. Eur J Vasc Endovasc Surg 2010;40(5): 628–34. [5] Hernandez-Richter T, Angele MK, Helmberger T, et al. Acute ischemia of the upper extremity: long-term results following thrombembolectomy with the Fogarty catheter. Langenbecks Arch Surg 2001;386(4):261–6. [6] Dryjski M, Swedenborg J. Acute ischemia of the extremities in a metropolitan area during one year. J Cardiovasc Surg 1984;25(6):518–22. [7] Turner EJ, Loh A, Howard A. Systematic review of the operative and nonoperative management of acute upper limb ischemia. J Vasc Nurs 2012;30(3): 71–6.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Simultaneous event of brachial artery occlusion and acute embolic stroke☆,☆☆ Abstract Although the rapid and accurate diagnosis of both acute ischemic stroke and extremity ischemia is essential to the timely and appropriate treatment, it is not always easy to differentiate between true stroke and stroke mimics. Although in general, limb ischemia due to extremity embolism is not included in stroke mimics or misdiagnosis, limb arterial embolism should be considered in the differential diagnosis of acute monoparesis because the diagnosis may be missed if the other typical manifestations of this presentation (pain, pallor, pulselessness, sensory loss, and coolness of the arm) are overlooked. Therefore, it is important to ensure that important signs are not missed whether the evaluation of the patient is done at the bedside. We report a case of a male patient presented to an emergency department with acute right upper extremity pain with headache, gait disturbance, and confused mentality. He was diagnosed by simultaneous brachial artery occlusion and acute stroke, which resulted in emergency surgical embolectomy and anticoagulation therapy. Rapid and accurate diagnosis of ischemic stroke is essential for timely and appropriate treatment with thrombolytic therapy. However, it is not always easy to differentiate between true stroke and stroke mimics. Patients who present with acute stroke mimics (ie, disorders that resemble stroke such as seizure, hypoglycemia, and psychogenic disorder) are incorrectly treated with thrombolytic therapy occasionally. Although, in general, limb ischemia due to extremity embolism is not included in stroke mimics or misdiagnosis [1,2], limb arterial embolism should be considered in the differential diagnosis of acute monoparesis because the diagnosis may be missed if the other typical manifestations of this presentation (pain, pallor, pulselessness, sensory loss, and coolness of the arm) are overlooked. We report a case of a male patient presented to an emergency department (ED) with acute right upper extremity pain with headache, gait disturbance, and confused mentality. He was diagnosed by simultaneous brachial artery occlusion and acute stroke, which resulted in emergency surgical embolectomy and anticoagulation therapy. A 73-year-old man presented to an ED with acute onset of right upper extremity pain, weakness, headache, gait disturbance, and confused mentality that had begun 5 hours ago. His medical history included hypertension, congestive heart failure, and ischemic heart disease. He has taken the β-blocker, diuretics, 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, and antiplatelet agent. The emergency physician diagnosed acute stroke and requested a neurologic consultation. The patient's blood pressure was 150/90 mm Hg, and a rhythm strip
☆ Conflicts of interest: None of the authors has any conflicts of interest to declare. ☆☆ Funding source: None of the authors has any funding source to declare.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
demonstrated atrial fibrillation rhythm at 88 beats per minute. Although he presented the right upper extremity weakness, the weakness of strength was not found on neurologic examination. Findings from the remainder of the neurologic examination, including speech and language, cranial nerves, coordination, right lower extremity strength, sensation, and reflexes and plantar responses, were normal. A computed tomographic (CT) scan of the brain showed no intracranial lesion except tissue loss due to old infarction in left frontal and right temporal lobes (Figure A). A magnetic resonance imaging and magnetic resonance angiography scan was performed to evaluate the confused mentality and subjective right upper arm weakness and showed acute infarction in right insula and temporoparietal lobes (Figure B). Because pain was a prominent feature of the presentation, the emergency physician checked a palpation of the right upper extremity for pulses. The right brachial and radial pulses were not palpable, and the right upper extremity was colder than the left upper extremity. An emergency right upper extremity enhanced CT was performed, which revealed a right brachial artery occlusion (Figure C and D). Intravenous heparin treatment was started, and the patient was transferred to the operating room for emergency right upper extremity exploration and embolectomy of the right brachial artery. A transthoracic echocardiogram performed for an intracardiac thrombus after the emergency operation was negative except small atrial septal defect with left to right shunt. He was transferred to department of neurology and treated for stroke accompanied by a right brachial artery occlusion. The patient recovered and was discharged home 13 days later with warfarin therapy. This patient illustrates that brachial artery occlusion can be occurred with stroke simultaneously. A brachial artery occlusion should be also considered in the differential diagnosis of paresis of the arm. The diagnosis may be missed if the typical manifestations of this presentation are overlooked. Age, female sex, atrial fibrillation, hypertension, diabetes, myocardial infarction, heart failure, and stroke are most common risk factors for thromboembolectomy of the upper limb [3]. Embolism from the heart is the major cause of upper limb ischemia. A Danish validation study of 1377 upper limb thromboembolectomies showed that 62.7% of patients had AF before or at the time of the admission for thromboembolectomy [4]. Upper limb thromboembolism is not as common as that of the lower limb. Lower limbs are approximately 4 times more commonly affected [5,6]. Symptoms of upper extremity arterial occlusion generally consist of pain, pallor, and sensory change as well as a loss of ulnar or radial pulses. Current treatment recommendations include immediate anticoagulation with heparin, surgical embolectomy, or intra-arterial thrombolytics and embolization. In systemic review article, operative management in acute upper limb ischemia was the most commonly used (86%), and an overall success rate of embolectomy showed 85% to 90% [7].
477.e4
S.H. Lee et al. / American Journal of Emergency Medicine 33 (2015) 477.e3–477.e4
Figure. a, The CT scans of a patient demonstrating no intracranial lesion except tissue loss by old infarction in left frontal and right temporal lobes. b, The diffusion-weighted magnetic resonance imaging scans of a patient showing acute infarction in right temporoparietal lobes. Three-dimensional reconstruction image of contrast-enhanced upper extremity CT demonstrating right brachial artery occlusion (c) and axial image of contrast-enhanced upper extremity CT demonstrating right brachial artery occlusion (arrow) (d).
Regardless of management, prompt treatment is warranted because upper extremity ischemia can lead to permanent loss of function. In this patient, a failure to recognize the brachial artery embolus could have resulted in further limb ischemia, gangrene, amputation, or death. Although the rapid identification of acute ischemic stroke is essential to the timely delivery of thrombolytics, careful and thorough examination with a complete history must be performed before specific treatment. Our case not only represents a rare simultaneous event of stroke and brachial artery occlusion but also emphasizes the importance of fundamental history taking and physical examinations in the evaluation of patients. Soo Hoon Lee, MD Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Republic of Korea Corresponding author. Department of Emergency Medicine Gyeongsang National University Hospital, Gangnam-ro 79 Jinju, Gyeongsangnam-do, Republic of Korea, 660-702 Tel.: + 82 55 750 8975; fax: +82 55 757 0514 E-mail address: [email protected] Nack-Cheon Choi, MD, PhD Department of Neurology, Gyeongsang National University Hospital Jinju, Gyeongsangnam-do, Republic of Korea In Seok Jang, MD, PhD Department of Thoracic Cardiovascular Surgery, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Republic of Korea
Tae-Sin Kang, MD Changwoo Kang, MD Jin Hee Jeong, MD Dong Seob Kim, MD Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do Republic of Korea http://dx.doi.org/10.1016/j.ajem.2014.08.049 References [1] Nor AM, Ford GA. Misdiagnosis of stroke. Expert Rev Neurother 2007;7(8): 989–1001. [2] Hand PJ, Kwan J, Lindley RI, et al. Distinguishing between stroke and mimic at the bedside: the brain attack study. Stroke 2006;37(3):769–75. [3] Andersen LV, Lip GY, Lindholt JS, et al. Upper limb arterial thromboembolism: a systematic review on incidence, risk factors, and prognosis, including a meta-analysis of risk-modifying drugs. J Thromb Haemost 2013;11(5): 836–44. [4] Andersen LV, Mortensen LS, Lindholt JS, et al. Upper-limb thrombo-embolectomy: national cohort study in Denmark. Eur J Vasc Endovasc Surg 2010;40(5): 628–34. [5] Hernandez-Richter T, Angele MK, Helmberger T, et al. Acute ischemia of the upper extremity: long-term results following thrombembolectomy with the Fogarty catheter. Langenbecks Arch Surg 2001;386(4):261–6. [6] Dryjski M, Swedenborg J. Acute ischemia of the extremities in a metropolitan area during one year. J Cardiovasc Surg 1984;25(6):518–22. [7] Turner EJ, Loh A, Howard A. Systematic review of the operative and nonoperative management of acute upper limb ischemia. J Vasc Nurs 2012;30(3): 71–6.
