Key Clinical Message
A 41-year-old man, known to have hypertension, who was admitted to the
emergency room after a car accident. He reported having a “feeling of
being drunk, but that he had not consumed alcohol” and complained of
dizziness, drowsiness, slow thinking, loss of strength in the limbs, and
ataxia. Brain imaging showed features compatible with a recent ischemic
infarction involving the anterior thalamic region and the adjacent
thalamo-diencephalic transition on the right.
Keywords: Hypertension, alcoholic intoxication, ataxia, car
accident and thalamic ischemic stroke.
INTRODUCTION
Sub-Saharan Africa has considerable deficits of epidemiological records,
however, an increase in deaths from cardiovascular events has been
estimated in the region. It is known that Africa suffers the greatest
impact worldwide by arterial hypertension, this being the most important
risk factor for the presence of stroke. In the literature, the incidence
of cerebral vascular events in the continent is located at 316 per 100
000 inhabitants and the prevalence at 981 cases per 100 000 inhabitants,
which constitutes a public health problema (1,2).
African countries face an increasing incidence of stroke, as do other
countries with low development index. Occurring 86% of fatalities from
this cause in these regions, in contrast to a decrease in the
presentation of these pathologies in developed countries (3).According
to a descriptive study conducted in a tertiary health center in Angola,
the most affected group were men over 55 years of age. In this study
series, the presence of hypertension was the main risk factor, followed
by heart disease and diabetes mellitus (4).
Strokes can happen at any time during various daily activities. People
collectively spend millions of hours behind the wheel each year. It’s
quite likely that some drivers experience a stroke while on the road,
and unfortunately, a portion of them may contribute to car accidents.
Research conducted in Japan indicates that 4.0% of all strokes occur
while driving, with accidents arising in 16% of these cases (5,6).
Furthermore, stroke can manifest with clinical features similar to acute
alcohol intoxication, characterized by mood swings, disinhibition, slow
thinking, reduced attention and concentration, incoordination, slurred
speech and unsteady gait (7,8).
This paper describes the evolution of a known hypertensive patient, who
was admitted to the emergency room of the Luanda Medical Center de (LMC)
complaining of dizziness, drowsiness, slow thinking, loss of strength in
the limbs, and ataxia, and who had a car accident. Brain imaging showed
features compatible with recent ischemic stroke.
CASE HISTORY/EXAMINATION
A 41-year-old male, black, reports having crashed his car into the back
of another car, had slow and incoherent speech and unstable gait, for
which he was subjected to 4 alcohol tests with negative results by
police agents. The next day, he comes to the emergency room at the
Luanda Medical Center referring to complaints that have evolved for 48
hours, characterized by “a feeling of drunkenness, but without alcohol
consumption”, dizziness, drowsiness, slow thinking, loss of strength in
the limbs and ataxic gait. Denies fever and headache. Personal history:
Arterial hypertension diagnosed about 4 years ago, medicated with
Perindopril + amlodipine 10/10mg/day: History of bilateral
hydronephrosis - Bilateral renal lithiasis: he underwent 3
ureteroscopies. Light ethanolic habits. Denies smoking. On physical
examination: Conscious, calm and cooperative, slow speech and
dysarthria, drowsy, eupneic,apyretic, anicteric, acyanotic, mucous
membranes, normal color and moist, good general and nutritional status.
Pulses: present, symmetrical and normowide, HR=63bpm, BP=140/89mmHg.
Cardiac auscultation:normophonetic and rhythmic heart tones, without
murmurs or extracts, Pulmonary auscultation conserved vesicular murmur,
without adventitious sounds. Abdomen.: Flat, mobile, normal RHA, not
painful on superficial or deep palpation, without palpable masses or
organomegaly and without signs of peritoneal irritation. Lower Limbs:
symmetrical, without deformities or edema, without signs of deep vein
thrombosis. Nervous System: Conscious, oriented, slow and coherent
speech, without meningeal signs or neurological focus, ataxic gait.
Osteotendinous reflexes II/IV in right hemibody.
METHODS (DIFFERENTIAL DIAGNOSIS, INVESTIGATIONS AND
TREATMENT)Regarding laboratory investigations his Hemoglobin 14.8, Total
cholesterol 241mg/dL, Triglycerides 151mg/dL, HDL 31mg/dL, LDL
180mg/dL, Creat 1.1mg/dL, Urea 13mg/DL, Uric acid 7.10mg/dL, Ionogram:
Na 140m/ equiv, K 4.3, Cl 1.5.
His ECG reveals Sinus Rhythm, HR=65bpm, without significant changes.
Echocardiogram: concentric LVH with preserved global systolic function
(EF=57%, LGS 16.4%). Cranioencephalic CT scan showed right anterior
thalamic ischemic infarction (Fig. A). Cerebral magnetic resonance
imaging - Describes aspects compatible with a recent ischemic
infarction, involving the anterior thalamic region and the adjacent
thalamo-diencephalic transition on the right (perforating vertebral
basilar territory), without significant mass effect or signs of
hemorrhagic transformation (Fig. B,c and D).
CONCLUSION AND RESULTS (OUTCOME AND FOLLOW-UP)
Based on the patient’s history, physical examination, and the
investigations mentioned above, the final diagnosis for the disease is
ischemic stroke, involving the anterior thalamic region and the adjacent
thalamo-diencephalic transition. The patient was medicated with
perindopril + amlodipine 10/10mg/day, atorvastatin 20mg/day and aspirin
100mg/day and was discharged completely recovered after 2 days of
hospitalization, without sequelae.
DISCUSSION
Occasionally, the literature reports instances of acute cardiovascular
events happening while driving (5,6,9,10). Most of these studies were
carried out by forensic scientists or accident investigators, focusing
on patients whose vascular events were severe enough to lead to
accidents (9,10). Previous studies have reported that about 4% of acute
strokes are driving-related, with ischemic strokes more likely to occur
while driving compared to hemorrhagic strokes (5,6).
The case report aligns with the trends observed in the literature,
emphasizing the impact of stroke on men over 55 years, with hypertension
being the predominant risk factor (11). This corroborates findings from
a descriptive study conducted in Angola, pointing towards a consistent
pattern in the region (4).
One noteworthy aspect is the association between stroke and automobile
accidents. The case of a known hypertensive patient experiencing a
stroke while driving, resulting in a car accident, underscores the
potential dangers and consequences. This scenario calls for increased
awareness and strategies to manage individuals with pre-existing health
conditions that may lead to sudden incapacitation, impacting their
ability to operate vehicles safely (5,6,10).
The clinical presentation of stroke can be diverse, as illustrated in
this case, where the patient exhibited symptoms mimicking acute alcohol
intoxication. This complexity emphasizes the need for healthcare
professionals to consider various manifestations of stroke, especially
when patients present with atypical symptoms (7,9).
The detailed case report elucidates the evolution of a hypertensive
patient who, despite negative alcohol tests, displayed symptoms
consistent with a alcohol intoxication. The imaging studies revealed an
ischemic infarction in the anterior thalamic region, highlighting the
importance of timely diagnostic procedures in stroke management.
Patients seeking treatment after more than 24 hours from the onset of
symptoms are usually not candidates for standard thrombolysis. This is
because over time, the potential benefits of thrombolysis decrease, and
the risks of complications, such as bleeding, become more prominent
(12).
The patient’s swift recovery without sequelae after receiving medical
intervention further underscores the significance of prompt and
effective treatment in mitigating the consequences of stroke.