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.