A 94-year-old woman admitted with confusion secondary to a urinary tract infection exhibited deformities in all four limbs that were present from birth. Her appearance was suggestive of split hand/split foot malformation a rare congenital condition that affects the central rays of the distal limb portion. She had no syndromic features and had lived without support or assistance of her daily activities. A keen knitter, she regularly knitted for her three grandchildren, all of which, along with her son, were unaffected by this condition.
A 33-year-old woman presented to the emergency department with an acute left partial anterior circulation ischaemic stroke. Thrombolysis was not administered due to a rapidly improving National Institutes of Health Stroke Scale (NIHSS) score and she was thereafter given appropriate treatment for secondary prevention. CT and MRI demonstrated a left basal ganglia infarct with haemorrhagic transformation. Initial investigations revealed no evidence of atrial fibrillation or large vessel disease. Further investigation with transthoracic, bubble contrast and transoesophageal echocardiogram all indicated the presence of a grade 1 tunnel-shaped patent foramen ovale (PFO) with some aneurysmal interatrial septum. No other cause for her stroke was found. There is no current evidence to support the routine use of percutaneous PFO closure in prevention of stroke or transient ischaemic attack. National guidelines advise transcatheter closure of PFO should only be considered for patients with recurrent cryptogenic stroke on optimal medical management.
Introduction:Intracerebral Hemorrhage (ICH) accounts for 10% of all patients presenting with acute stroke in the United Kingdom (UK).The 30-day mortality from ICH ranges from 35 to 52 per cent one-half of these deaths occur within the first two days. The significant mortality associated with ICH poses a significant challenge for the clinician, particularly with regard to decision-making around the 'appropriateness' of interventions, which may not improve or support the short-term or long-term outcomes. Aim: To examine whether the Essen Score in conjunction with dysphagia assessments could aid prognostication and decision-making, particularly with regards to artificial nutritional support and end-of-life care decision-making in patients with ICH. Materials and Methods: We retrospectively reviewed the notes of 42 patients admitted to our Stroke Unit with a primary diagnosis of spontaneous ICH, between December 2011 and June 2013. Data on survival, mortality, presence of dysphagia, and the utilization of artificial nutrition were recorded. The Essen score was applied to the same cohort of patients, with subsequent comparison of the predicted and actual outcomes. Result: Sixteen patients (38%) had an Essen score >7, with an average survival of three days. Ten patients (24%) had Essen scores <3. To date the average survival in this group is 305 days. Conclusion: We would postulate that discussions with the families of ICH patients presenting with Essen scores >7 and total dysphagia, need to focus on limiting any invasive medical treatment, including the use of artificial feeding, among cases highly unlikely to benefit from it. This highlights the potential use of the Essen score as a tool in conjunction with clinical judgment, to facilitate discussions around short-term and long-term goals set for individual patients, among the multidisciplinary team, family, and carers.
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