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What causes sudden weakness in the upper and lower limbs?

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Posted on Thu, 28 Jul 2016
Question: Patient VTK age 45 years on 12 feb @ 15:45 with complaints of sudden onset weakness in upper & lower limb on 12 Feb @ 14:15.
CT brain shows slightly hypodense right MCA. There was no infarct or bleed.
@ 16:30 Inj TNK-TPA 7ml (14 mg) IV single Bolus dose administered..
Post thrombolysis initial 24 hrs patient was stable. Repeat CT Brain after 24 hrs showed wel defined right MCA infarct with mild mass effect & effacemant of right lateral ventricle. This suggests that patient did not have desired effect of Tenectaplase. There was no evidance of bleed. She was started on single antiplatelet & LMWH as per the protocol, inj Lupinox .4 ml s/c 1st dose was given @ 6 PM on 13 Feb.
From 14 feb it was advised to give BD dose as per the protocol.
Post thrombolysis 48 hrs CT scan performed showed acute right MCA teritory infarct with increase in the mass effect of the form of compression of right lateral ventricle & mid-line shift to left side of 7.5 mm. Patient was closly monitered for sign of raised IC pressure, in the form drowsiness.
On Feb 15, @ 12:10 patient became progressivly drowsi & had bradycardia with Pupillary asymmetry. Patient was intubated & patient was posted of urgent decompression hemicraniotomy.

Kindly suggest the whether this worsening of the symptoms observed on acoount of adverse effect of TNK - TPA or other Medication i.e. LMWH or on account of other pathology in this case.
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Answered by Dr. Sudhir Kumar (2 hours later)
Brief Answer:
Worsening was most likely due to the malignant ischemic stroke

Detailed Answer:
Hi,

Thank you for posting your query.

I am Dr Sudhir Kumar, Neurologist, with special interest in stroke management. I would try my best to resolve your query.

Based on the case details, she had a large MCA territory infarct. Dense right MCA sign indicated the severity. In fact, in our stroke unit, we do not thrombolyse a patient, if dense MCA sign is present (this is because thrombolysis does not help such subgroup of patients). So, it is not surprising to note that she did not improve after thrombolysis.

Subsequently, what happened was the natural progression of a malignant (large) MCA territory stroke. The mass effect continued to increase and patient worsened due to herniation.

An early decompressive hemicraniectomy (within 24 hours of symptom onset) may have been more helpful.

I sincerely hope my reply has helped you.

I would be pleased to answer, if you have any follow up queries or if you require any further information.
     
Best wishes,     
Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology) XXXXXXX Consultant Neurologist
Apollo Hospitals, XXXXXXX
For DIRECT QUERY to me: http://bit.ly/Dr-Sudhir-kumar
My blog: http://bestneurodoctor.blogspot.com/

Above answer was peer-reviewed by : Dr. Veerisetty Shyamkumar
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Dr. Sudhir Kumar

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Practicing since :1994

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What causes sudden weakness in the upper and lower limbs?

Brief Answer: Worsening was most likely due to the malignant ischemic stroke Detailed Answer: Hi, Thank you for posting your query. I am Dr Sudhir Kumar, Neurologist, with special interest in stroke management. I would try my best to resolve your query. Based on the case details, she had a large MCA territory infarct. Dense right MCA sign indicated the severity. In fact, in our stroke unit, we do not thrombolyse a patient, if dense MCA sign is present (this is because thrombolysis does not help such subgroup of patients). So, it is not surprising to note that she did not improve after thrombolysis. Subsequently, what happened was the natural progression of a malignant (large) MCA territory stroke. The mass effect continued to increase and patient worsened due to herniation. An early decompressive hemicraniectomy (within 24 hours of symptom onset) may have been more helpful. I sincerely hope my reply has helped you. I would be pleased to answer, if you have any follow up queries or if you require any further information. Best wishes, Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology) XXXXXXX Consultant Neurologist Apollo Hospitals, XXXXXXX For DIRECT QUERY to me: http://bit.ly/Dr-Sudhir-kumar My blog: http://bestneurodoctor.blogspot.com/