This Will Be A Long Message So My Apologies For

Brief Answer:
Stroke in evolution vs. completed stroke vs. new stroke

Detailed Answer:
So sorry to hear about your brother and hopefully he will begin to turn the corner. I'd like to provide you with some information which will help clarify and hopefully give some additional information on what you're already self teaching (very commendable that you are reading up on this complex topic) on cerebrovascular disease. Let's go item by item through your message and that way we'll cover the bases.

According to the information your brother is 49 years old. He was admitted to the hospital 5 days ago for symptoms of right sided weakness with what is described as weakness in the leg which required "a little assistance to ambulate." He also retained use of the right arm and hand though this was apparently weakened as well.

I am going to make some assumptions as to what your brother looked like upon admission to the hospital on Tuesday just based on this information though it would nicer to hear you relate some additional specific information but here is my assessment of his condition on Tuesday.

It appears that he developed some mild to moderate weakness of the arm and leg on the right side for which he needed some assistance to ambulate but perhaps not much assistance for holding things in the right hand. Therefore, the weakness in the right upper and lower extremity can be thought of as being approximately EQUAL in their severity. Is that a fair statement? In other words, the overall degree of weakness when admitted was mild to moderate and the amount of weakness in the right upper extremity could be said to have been approximately equal to the weakness of the right leg. There did not appear to be any right facial weakness at that time since you didn't mention it although maybe there could've been and you or the doctors just didn't notice it?

Within 12-24 hrs. of being admitted to the hospital the severity of the weakness in both right upper and lower extremities became SEVERE which I interpret as meaning that now within 1 day of admission he could be described (in textbook verbiage if you will) as having a DENSE HEMIPARESIS (WEAKNESS over half the body) involving the right arm and leg meaning that now there was little to no effective use of either limb. Is this accurate?

You also state that an MRI of the brain showed blockage of VEINS in the left hemisphere. Let me take the XXXXXXX of sharing some information that in all likelihood what the MRI demonstrated were blockages of DISTRIBUTIONS in the deep white matter of infarct (stroke) supplied by what we refer to as deep penetrating arteries (coming from the MIDDLE CEREBRAL ARTERY) which probably involved either the BASAL GANGLIA or the INTERNAL CAPSULE which are anatomic locations important for motor movement to occur. I'm also supposing that he is not complaining of any deficits in terms of FEELING STIMULATIONS on the skin such as touch, temperature, pain, etc. In other words, your brother is demonstrating a PURE MOTOR STROKE over half the body.

I want to underscore the difference between VENOUS and ARTERIAL OBSTRUCTIONS since you mentioned "veins." Please let me know whether in fact the blockages that the neurologist called were arterial or venous components or maybe he really didn't say. It is RARELY THE CASE that this type of picture involves blockages of the VEINS. We tend to find ARTERIAL OR ARTERIOLAR OCCLUSIONS in these types of strokes. Venous occlusions in the brain lead to a much different presentation compared to what you're describing so that's why the distinction is important.

You say they did an ANGIOGRAM. Now, are you referring to an actual vascular study where a catheter was inserted into the groin or the arm, snaked up into the carotid artery on the left side then, injected with iodine (or some newer substance depending on the hospital) with pictures being taken for the purpose of visualizing the blockages and their locations? If this procedure was NOT undertaken then, the angiogram you're talking about could've been what we refer to as either an MRA (angiogram done by magnetic resonance imaging which is NONINVASIVE) or even a CTA (angiogram done by CAT SCAN technology) which is being done frequently nowadays in place of the MRA (personally, I like the MRA's over CTA's due to the difference in radiation exposure with CT technology vs. no exposure with MR technology).

You then, go on to say that the neurologist commented that the blood thinners seemed to helping that placing STENTS would not be necessary. Could you clarify for me the TYPE OF BLOOD THINNERS your brother was given? If he was given ANTICOAGULANTS such as Coumadin, Eliquis, or Xarelto then, there would be some further information necessary to look into such as, was he found to have Atrial Fibrillation, blood clots or THROMBI in the heart, or DEEP VENOUS THROMBOSES (blood clots in the calves) detected by Ultrasound? Or was he placed on blood thinners designated as ANTIPLATELET MEDICATIONS such as aspirin, Plavix, or Aggrenox?

Next, he remained stable with this clinical picture of severe weakness on the right side over the following 48 hrs. and it would appear you mention that he did have some type of a facial droop on the right side that accompanied the weakness in the right extremities and there were intermittent times he could make a fist on the right but other times he could not. He was then, transferred to rehab on Friday afternoon. He was ordered PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY and this tells me that in fact, there was probably facial involvement right from the get go of this whole thing though you didn't really mention it on Tuesday's presentation. My guess is that he has had SLURRED speech, or DYSARTHRIA as opposed to inability to understand speech or know what he wants he wants to say. This is to say that he likely does not have an APHASIA of any sort and the speech therapy is ordered to help him "get the marbles out of his mouth"....so to speak, yes?

By Saturday, the hemiparesis became hemiPLEGIA (paralysis) over the right side with accentuation of the right lower facial droop. There is also some swallowing difficulty noted but not enough to cause choking of any significance or alter his ability to enjoy meals.

And now to your QUESTION: "Is having a worsening of stroke symptoms over the course of days something that can happen?"

ANSWER: Yes, worsening of stroke symptoms as you are describing what is most likely a SMALL VESSEL ISCHEMIC or MICROVASCULAR basal gangliar stroke is an entity that often starts out much milder than where it lands several days later. Unfortunately, these types of strokes occur with quite a high frequency in first time stroke victims if they have any of the risk factors such as HYPERTENSION, DIABETES MELLITUS, HYPERCHOLESTEROLEMIA, SMOKER, PERIPHERAL ARTERIAL DISEASE/ATHEROSCLEROTIC DISEASE. IN the phenomenon of EMBOLIC STROKE the maximal deficit or dysfunction of the brain generally is thought to occur within the first few hours following the stroke (if untreated) and certainly by 24 hrs. With your brother's case the stroke EVOLVED and then, COMPLETED itself. I do not believe he suffered a 2nd or separate stroke apart from what he had. A repeat MRI with perfusion and diffusion weighted imaging could prove that hypothesis.

I don't think either you nor your brother's doctors have "missed" anything. This is a typical progression seen in this type of stroke and treatment is focused at:

1. Treating the weakness and dysarthria using as aggressive a therapy program as the patient is able to handle.

2. Addressing the risk factors that led or caused the stroke in the first place.

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating if you feel so inclined? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in knowing how things evolve for your brother- especially if you get any testing done so drop me a line please and I'm hoping all the best for you.

This query has utilized a total of 60 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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Brief Answer:
Stroke in evolution vs. completed stroke vs. new stroke

Detailed Answer:
So sorry to hear about your brother and hopefully he will begin to turn the corner. I'd like to provide you with some information which will help clarify and hopefully give some additional information on what you're already self teaching (very commendable that you are reading up on this complex topic) on cerebrovascular disease. Let's go item by item through your message and that way we'll cover the bases.

According to the information your brother is 49 years old. He was admitted to the hospital 5 days ago for symptoms of right sided weakness with what is described as weakness in the leg which required "a little assistance to ambulate." He also retained use of the right arm and hand though this was apparently weakened as well.

I am going to make some assumptions as to what your brother looked like upon admission to the hospital on Tuesday just based on this information though it would nicer to hear you relate some additional specific information but here is my assessment of his condition on Tuesday.

It appears that he developed some mild to moderate weakness of the arm and leg on the right side for which he needed some assistance to ambulate but perhaps not much assistance for holding things in the right hand. Therefore, the weakness in the right upper and lower extremity can be thought of as being approximately EQUAL in their severity. Is that a fair statement? In other words, the overall degree of weakness when admitted was mild to moderate and the amount of weakness in the right upper extremity could be said to have been approximately equal to the weakness of the right leg. There did not appear to be any right facial weakness at that time since you didn't mention it although maybe there could've been and you or the doctors just didn't notice it?

Within 12-24 hrs. of being admitted to the hospital the severity of the weakness in both right upper and lower extremities became SEVERE which I interpret as meaning that now within 1 day of admission he could be described (in textbook verbiage if you will) as having a DENSE HEMIPARESIS (WEAKNESS over half the body) involving the right arm and leg meaning that now there was little to no effective use of either limb. Is this accurate?

You also state that an MRI of the brain showed blockage of VEINS in the left hemisphere. Let me take the XXXXXXX of sharing some information that in all likelihood what the MRI demonstrated were blockages of DISTRIBUTIONS in the deep white matter of infarct (stroke) supplied by what we refer to as deep penetrating arteries (coming from the MIDDLE CEREBRAL ARTERY) which probably involved either the BASAL GANGLIA or the INTERNAL CAPSULE which are anatomic locations important for motor movement to occur. I'm also supposing that he is not complaining of any deficits in terms of FEELING STIMULATIONS on the skin such as touch, temperature, pain, etc. In other words, your brother is demonstrating a PURE MOTOR STROKE over half the body.

I want to underscore the difference between VENOUS and ARTERIAL OBSTRUCTIONS since you mentioned "veins." Please let me know whether in fact the blockages that the neurologist called were arterial or venous components or maybe he really didn't say. It is RARELY THE CASE that this type of picture involves blockages of the VEINS. We tend to find ARTERIAL OR ARTERIOLAR OCCLUSIONS in these types of strokes. Venous occlusions in the brain lead to a much different presentation compared to what you're describing so that's why the distinction is important.

You say they did an ANGIOGRAM. Now, are you referring to an actual vascular study where a catheter was inserted into the groin or the arm, snaked up into the carotid artery on the left side then, injected with iodine (or some newer substance depending on the hospital) with pictures being taken for the purpose of visualizing the blockages and their locations? If this procedure was NOT undertaken then, the angiogram you're talking about could've been what we refer to as either an MRA (angiogram done by magnetic resonance imaging which is NONINVASIVE) or even a CTA (angiogram done by CAT SCAN technology) which is being done frequently nowadays in place of the MRA (personally, I like the MRA's over CTA's due to the difference in radiation exposure with CT technology vs. no exposure with MR technology).

You then, go on to say that the neurologist commented that the blood thinners seemed to helping that placing STENTS would not be necessary. Could you clarify for me the TYPE OF BLOOD THINNERS your brother was given? If he was given ANTICOAGULANTS such as Coumadin, Eliquis, or Xarelto then, there would be some further information necessary to look into such as, was he found to have Atrial Fibrillation, blood clots or THROMBI in the heart, or DEEP VENOUS THROMBOSES (blood clots in the calves) detected by Ultrasound? Or was he placed on blood thinners designated as ANTIPLATELET MEDICATIONS such as aspirin, Plavix, or Aggrenox?

Next, he remained stable with this clinical picture of severe weakness on the right side over the following 48 hrs. and it would appear you mention that he did have some type of a facial droop on the right side that accompanied the weakness in the right extremities and there were intermittent times he could make a fist on the right but other times he could not. He was then, transferred to rehab on Friday afternoon. He was ordered PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY and this tells me that in fact, there was probably facial involvement right from the get go of this whole thing though you didn't really mention it on Tuesday's presentation. My guess is that he has had SLURRED speech, or DYSARTHRIA as opposed to inability to understand speech or know what he wants he wants to say. This is to say that he likely does not have an APHASIA of any sort and the speech therapy is ordered to help him "get the marbles out of his mouth"....so to speak, yes?

By Saturday, the hemiparesis became hemiPLEGIA (paralysis) over the right side with accentuation of the right lower facial droop. There is also some swallowing difficulty noted but not enough to cause choking of any significance or alter his ability to enjoy meals.

And now to your QUESTION: "Is having a worsening of stroke symptoms over the course of days something that can happen?"

ANSWER: Yes, worsening of stroke symptoms as you are describing what is most likely a SMALL VESSEL ISCHEMIC or MICROVASCULAR basal gangliar stroke is an entity that often starts out much milder than where it lands several days later. Unfortunately, these types of strokes occur with quite a high frequency in first time stroke victims if they have any of the risk factors such as HYPERTENSION, DIABETES MELLITUS, HYPERCHOLESTEROLEMIA, SMOKER, PERIPHERAL ARTERIAL DISEASE/ATHEROSCLEROTIC DISEASE. IN the phenomenon of EMBOLIC STROKE the maximal deficit or dysfunction of the brain generally is thought to occur within the first few hours following the stroke (if untreated) and certainly by 24 hrs. With your brother's case the stroke EVOLVED and then, COMPLETED itself. I do not believe he suffered a 2nd or separate stroke apart from what he had. A repeat MRI with perfusion and diffusion weighted imaging could prove that hypothesis.

I don't think either you nor your brother's doctors have "missed" anything. This is a typical progression seen in this type of stroke and treatment is focused at:

1. Treating the weakness and dysarthria using as aggressive a therapy program as the patient is able to handle.

2. Addressing the risk factors that led or caused the stroke in the first place.

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating if you feel so inclined? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in knowing how things evolve for your brother- especially if you get any testing done so drop me a line please and I'm hoping all the best for you.

This query has utilized a total of 60 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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