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Point of Care Ultrasonography in the Evaluation and Management of Hypertension and Chest Pain in a Patient with Acute Ischemic Stroke

By Currents Editor posted 03-28-2022 08:10

  

Mikel Shea Ehntholt
Neurocritical Care Fellow, Hospital of the University of Pennsylvania
Department of Neurology

A 73-year old woman presented to our institution with a three-week duration of headache and dizziness. She had a past known history of an aneurysmal subarachnoid hemorrhage, secondary to a posterior communicating aneurysm that was coiled five years prior, hypertension, and hyperlipidemia.  Her symptoms prompted an outpatient evaluation and was recommended for repeat digital subtraction angiography (DSA). On the day of the DSA she was noted to be hypertensive with a new R CN III vertical gaze palsy and was referred to the emergency department (ED). In the ED she was hypertensive to systolic of 225, with an NIHSS of 1 for partial gaze palsy. CTH was without evidence of acute hemorrhage. Tissue plasminogen activator (tPa) and mechanical thrombectomy were deferred given she was outside of the therapeutic window and symptoms were not consistent with a large vessel occlusion.  

On admission to the Neuro-ICU, her blood pressure was aggressively controlled with intravenous nicardipine to target goal systolic blood pressure (SBP) <140. She subsequently developed chest pain and nausea that radiated to her left shoulder. Electrocardiogram showed ischemic changes, and she was treated with sub-lingual nitroglycerin. Laboratory data was significant for rising troponins consistent with a non-ST segment myocardial infarction for which cardiology was consulted. She was started on nitroglycerin and heparin drips per acute coronary syndrome protocol. Point-of-care ultrasound (POCUS) echocardiography revealed no segmental wall motion abnormalities or asymmetric myocardial dysfunction to suggest ongoing ischemia. Left ventricle hypertrophy (LVH) was subjectively noted on multiple views, as well as significant aortic stenosis (AS), and moderate to severe thickening of the aortic valve with reduced systolic flow through the left ventricular outflow tract on color doppler (as shown in video below.) These findings were consistent cardiac remodeling and valvular disease in the setting of chronic HTN making the patient preload dependent. 


The management of the patient’s symptoms secondary to the severity of the AV pathology and chronic HTN was challenging. Astute diligence was required to balance cardiac preload via volume status and blood pressure goals to maintain adequate coronary perfusion pressure. Serial POCUS assessments were performed throughout the patient’s hospital course to achieve this balance. As seen in Figures 1 and 2, the patient’s LV was moderately hypertrophied on the parasternal long axis view (PSLAX). A thin systolic jet traversed a stenotic and calcified aortic valve in the left ventricular outflow tract. In Figure 3. the patient’s LV on parasternal short axis (PSSAX) views was concentrically hypertrophied with a prominent mitral valve further characterizing the degree of LVH. In Figure 4. POCUS assessment of the IVC in the subcostal view (SCLAX) was repeatedly monitored as a surrogate for fluid status. Lung ultrasound in addition to chest radiographs and daily fluid balance were monitored for signs of fluid overload.  

Once stabilized, the patient was taken for a left heart catheterization (LHC) that showed no CAD. A formal TTE was obtained which showed moderate AS with hypertensive heart disease and marked LVH. Left ventricular ejection fraction (LVEF) was 75% with a moderately thickened and calcified AV tri-leaflet, moderately reduced excursion of the AV with moderate AS with an AV peak gradient measures 42 mmHg (moderate >40, severe >641), mean gradient measures 25 mmHg (moderate >20, severe >402) and AV dimensionless valve index of 0.5 (moderate <0.5, severe <0.253) with no aortic regurgitation.  

Patient was stabilized post LHC and had no further cardiac complaints. DSA revealed proximal stent migration and residual filling at base of neck of aneurysm, after which the patient underwent repeat stent-assisted coil embolization. She was restarted on aspirin, clopidogrel, and statin for secondary stroke prevention. 

POCUS is frequently used by intensivists for the bedside evaluation and management of shock, respiratory failure, and cardiac arrest. Applications of this skill set are particularly useful in the evaluation critically ill patients with neurologic injuries. In this case it was essential to the appropriate triage and treatment of acute neurologic and cardiac symptoms, timely intervention by consultants, and planning for neuro-intervention and post procedural management. With the aid of POCUS, neuro-intensivists in this case were able to identify a patient that was chronically hypertensive and cardiac preload dependent. Rapid reduction of BP to achieve standard goals for acute management of an intracranial hemorrhage likely resulted in reduction in cardiac output and resultant myocardial ischemia. Adequate fluid resuscitation and close volume status monitoring was required while the patient remained NPO for procedures. Additionally, the knowledge of the patient’s underlying structural pathology also allowed intensivists to contribute to the discussion of the timeliness of surgical intervention, risk stratification peri-procedurally, and need for dual anti-platelet therapy (dAPT) post procedure. 

Often neuro-intensivists and vascular neurologists are required to weigh the intracranial bleeding risk against cardiac, pulmonary, and or renal concerns. Simultaneously balancing the interplay of these organ systems with the use of POCUS ultrasound can be invaluable and was integral to the favorable outcome in this patient. 

Fig1-4: Parasternal long axis (PSLAX), parasternal short axis (PSSAX), and subcostal long axis (SCLAX) views on POCUS echocardiography. Note, the thickened left ventricle with a significantly narrow left ventricular outflow tract secondary to a thickened and calcified aortic valve. Color doppler was applied in Fig 2 and demonstrated a subjective reduction in flow through this aortic valve. Fig 3 at the level of the mitral valve highlights a hypertrophied LV. The subcostal long axis view highlights a plethoric IVC leading into the right atrium. Vid 1 highlights Fig 1-2 in real time. 


References

  1. Nanditha S, Malik V. Comparison of flow-independent parameters for grading severity of aortic stenosis using intraoperative transesophageal echocardiography
  2. Rajani R, Hancock J, Chambers JB. The art of assessing aortic stenosis.
  3. Nanditha S, Malik V. Comparison of flow-independent parameters for grading severity of aortic stenosis using intraoperative transesophageal echocardiography

POCUS Article Submission Guidelines 

The ultrasound section of  Currents focuses on the use of point of care ultrasonography (POCUS) in the management of patients in the neurological intensive care unit. The authors should provide a synopsis of the case, review POCUS findings with image and video (if available), address key technical considerations in performing the scan, and discuss the utility and limitations of the exemplified POCUS technique on patient management.

Words ≤1000, Images ≤ 4, Videos ≤ 4, Citations ≤ 10

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