Abstract Details

Title Not Making a List: The Agraphic Santa Claus and the Limitations of NIHSS

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P3 - Poster Session 3 (5:30 PM-6:30 PM)

Poster/Presentation
Number 3-070

Objective NA

Background A 57 year old right-handed male with a history of hypertension, hyperlipidemia, and type 2 diabetes presented with agraphia and LLE weakness. The patient stated he was writing cards when he found that he was suddenly unable to write the words he wished to express. Associated symptoms included weakness of his left leg. He was otherwise without expressive or receptive communication abnormality, including completely intact verbal communication.

Design/Methods NA

Results Primary consideration was for acute stroke. Symptoms of extremity weakness resolved, resulting in NIHSS 0. The patient continued to manifest isolated agraphia without other language impairment. CT scan of the head was unremarkable. The patient’s employment primarily entailed paperwork and activities as a professional Santa Claus. Given that the patient’s livelihood was dependent on his ability to write, symptoms were considered significantly disabling. After discussion, the decision was made to administer intravenous alteplase (IV-tPA). Soon after administration, neurological symptoms resolved. MRI brain showed no evidence of ongoing ischemia. Patient was found to have PFO as well as strong family history of prothrombin mutation. Further assessments revealed no evidence of DVT. Patient was discharged for further stroke workup in the outpatient setting.

Conclusions While the formal NIHSS remains the primary means by which severity of stroke symptoms is assessed, there are limits to its applicability as it pertains to the diversity of real-world cases. It is important to remember that disabling symptoms of stroke are unique to each individual patient. An NIHSS 0 for no neurologic symptoms is not equivalent to an NIHSS 0 for disabling agraphic symptoms. Assessment of acute stroke and its long-term sequelae is not as rote as checking a series of boxes and tabulating a score. There is an art in the assessment of stroke patients and applying the therapies to ensure that each unique patient receives appropriate management.

Authors/Disclosures
Micah Etter, MD (University of Arizona Neurology) PRESENTER	Dr. Etter has nothing to disclose.
Preeth Manu, MD (Medical College of Georgia at Augusta University)	No disclosure on file
Mohammad H. El-Ghanem, MD (Neuroendovascular Surgery - Northwest Medical Center)	Dr. El-Ghanem has nothing to disclose.

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