An unusual case of stroke in a young adult

Journal of Family Practice, April, 1997 by David C. Robinson

Cerebral vascular accidents are uncommon in young of middle-aged adults, and when they occur, the more common risk factors for stroke include hypertension, diabetes mellitus, hyperlipidemia, acquired immunodeficiency syndroms (AIDS), heavy alcohol consumption, and a family history of stroke. (1) Less commonly known risk factors mad causes of stroke in the young of middle-aged adult include inactivity (3.1 strokes per 1000 men per year compared with 0.5 strokes per 1000 men per year for men actively engaged in vigorous exercise) (2); cigarette smoking in men (relative risks of nonfatal and fatal stroke were 2.52 and 1.24, respectively, for men smoking 20 or more cigarettes per day) (3); cocaine use (4); atrial fibrillation with other clinical risk factors (ie, recent congestive heart failure, history of hypertension, or previous atrial thromboembolism) (5); atrial myxomas (6); and being black (a substantially higher risk of intracerebral and subarachnoid hemorrhage than in whites). (7)

* CASE REPORT

A 40-year-old white man developed a sudden change in mental status; he was unable to communicate or follow commands, and was in a state of confusion. Paramedics were summoned to his home and found the patient to have no evidence of trauma, but he had global aphasia with right-sided weakness of the upper extremity more than the lower extremity; his blood pressure was 210/140 mm Hg. The patient had a past medical history for hypertension and hyperlipidemia and was regularly taking antihypertensive medication, ie, lisinopril 20 mg daily. He had no history of diabetes mellitus, heart palpitations, alcohol or drug use, prior thromboembolic episodes, cigarette smoking, or family history of stroke. He was treated for hypertension en route to the emergency department.

In the emergency department, the patient was awake but disoriented. He was aphasic, unable to follow simple commands, and made inappropriate responses to questions posed by emergency department personnel. The patient's blood pressure was 120/56 mm Hg, his pulse 95 beats per minute, oral temperature 96.6[degrees]F (35.9[degrees]C), and respirations 16 per minute. The right side of the patient's face drooped and his tympanic membranes were clear, with no hemotympanum. There was no thyromegaly. No carotid bruits were auscultated. An examination of the heart and lungs revealed no abnormalities. The abdomen was soft and nontender, and there was no hepatosplenomegaly.

A neurologic examination revealed that the pupils were sluggish but reactive to light. Extraocular muscles were intact; accommodation could not be tested. Fundi showed no papilledema, and visual fields were hard to assess. Conjugate gaze was with left preference. There was minimal flattening of the right nasal labial fold. Other cranial nerves could not be assessed. Deep tendon reflexes of the brachial radialis, triceps, and patella were 3 on the right side and 2 on the left. The Achilles tendon reflex was 2 bilaterally with a questionable Babinski sign on the right side. Decreased motor function and muscle tone were greater on the right upper extremity than on the right lower extremity, with strong sensory pain withdrawal on the left side compared with the right.

Laboratory evaluations revealed the following values: white blood cell count (WBC) 8.6 x [10.sup.3]/[mm.sup.3], hemoglobin 14.4 g/dL, hematocrit 42.0%, platelet count 220 x [10.sup.3]/[mm.sup.3], neutrophils 84%, lymphocytes 8%, monocytes 7%, and eosinophils 1%. Sodium level was 135 mEq/L, potassium 3.7 mEq/L, chloride 100 mEq/L, C[O.sub.2] 23 mEq/L, BUN 15 mg/dL, creatinine 1.0 mg/dL, glucose 120 mg/dL, and sedimentation rate 6 mm/h. Total cholesterol was 207 mg/dL and triglycerides 168 mg/dL. The drug and alcohol screening tests were negative. An ANA test was within normal limits. Arterial blood gases on room air showed a pH of 7.4, PC[O.sub.2] at 38 mm Hg, P[O.sub.2] at 96.8 mm Hg, and bicarbonate 25 mEq/L.

A lumbar puncture was within normal limits. A computed tomographic (CT) scan of the brain showed no evidence of hemorrhage. Doppler ultrasongraphy of the carotid artery was negative. Transthoracic echocardiography showed no mass, thrombi, or valvular abnormality. An electrocardiogram (ECG) showed normal sinus rhythm with no ectopy or ST changes. A magnetic resonance imaging scan (MRI) of the brain 2 days later showed basal ganglia and temporal m/d parietal ischemic changes on the left side compatible with a left middle cerebral artery infarct.

Although the standard workup of the patient revealed no abnormalities, including a transthoracic echocardiogram that failed to show any cardiac thrombus or tumor, other conceivable causes had to be investigated before the patient's condition was diagnosed as an idiopathic stroke and he was sent for rehabilitation. (6) In this case, the patient had a transesophageal echocardiogram that revealed a 3.0-cm left atrial myxoma, the cause for his embolic stroke. This was done as a result of wanting to leave "no stone unturned." If the patient had been sent off to rehabilitation without this diagnosis, stroke recurrence would be extremely high with devastating results in the young adult, such as permanent brain necrosis from atrial myxoma showers. (6) The patient was transferred to a tertiary care medical center, where open heart surgery and removal of the benign atrial myxoma was completed without incident.