A middle aged man presented with vertigo and visual disturbances, had history of stroke few months back.

1. DR. MD. AZIZUL HAKIM
MD RESIDENT, PHASE-A
(PSYCHIATRY)
SOMCH
A middle aged man presented
with vertigo & visual
disturbance.

2. Particulars of the patient
 Name: Mr. Syed Ali
 Age: 45 years
 Sex: Male
 Religion: Islam
 Occupation: Jobless
 Address: Chatok,
Sunamgonj
 Ward: 27
 Unit: MMU-IV
 Bed: 28
 Reg. no.: 7664
 Date of Admission:
21.03.19
 Informant: Patient &
his wife
 Referral: from Chatok
UHC
 Admitted via
Emergency dept.
SOMCH

3. Presenting complaints
 Weakness of right side of the body for 5 months
 Loss of sensation of right side of the body for 5
months
 Vertigo & blurring of vision for 5 days

4. H/O Presenting complaints
 According to the statement of the patient &
informant, he was reasonably well 5 months back.
One day, suddenly in the early morning, while going
to the toilet he felt weakness of the right side of the
body, initially in the upper limb, then the right lower
limb, followed by fall to the ground. He was unable
to move his right side of the body & couldn’t walk.

5. H/O PC Continue…
 He also developed slurred speech & difficulty in
swallowing but there was no loss of consciousness.
With this complaints patient was taken to a nearby
private hospital in Sunamgonj. After doing a CT scan
of brain diagnosed as a case of stroke. The document
couldn’t be shown.

6. H/O PC Continue…
 The patient was discharged on request. Within few
days of returning home patient felt numbness &
tingling sensation to the right side of the body
initially, then developed loss of sensation as well. He
came to the traditional healer, who treated him &
advised to take hot compression. Some parts of right
leg & foot was burnt during hot compression. Patient
was treated for it locally.

7. H/O PC Continue…
 For the last 5 days prior to admission he developed
vertigo & blurring of vision, both vertigo & blurring
of vision was sudden, episodic, spinning around,
related to posture, aggravated at sitting & standing
position, relieved by lying, not associated with
hearing loss, tinnitus or headache. With these
complaints he went to Chatok UHC & referred to
SOMCH for better management.

8. H/O PC Continue…
 On query, he also complained mild to moderate pain
to the right side of the body which was intermittent,
pricking in nature, not relieved by NSAIDs. He has
also pain in the right shoulder joint & limitation of
movement. He has no complain regarding left side of
the body, his has no difficulty in swallowing, his
slurred speech is now almost near to normal voice.
He had no episode of loss of consciousness,
convulsion, trauma to the head, nausea, vomiting,
double vision or abnormal movement. His bowel &
bladder habit was normal.

9. H/O PC Continue…
 He has no complain of fever, cough, breathlessness,
chest pain, abdominal discomfort, jaundice, thirst,
frequent micturition, weight loss, dysuria, etc.

10. H/O Past Illness
 No significant past medial & surgical history except
history of minor surgery in right hand following
machinery injury to the work place 10 years back.

11. Family history
 His father & mother both were died by age related
complications. No consanguinity of marriage
between them.
 2 siblings, he is youngest.

12. Family pedigree
p
MF
w
DS

13. Personal history
 His early childhood was nothing contributory.
 Studied up to class four.
 Lived in Kuwait for 30 years, worked in a plastic
company in machinery dept.. Got salary about
75000 BDT. He sent his money to his brother’s
account & exploited by him as he complained.

14. Personal history cont…
 Now he is jobless for 2 years after returning from
Kuwait.
 Married for 7 years, 2 children.
 No history of extra-marital sexual exposure, drug
abuse.
 He is a smoker. Smokes 15 sticks/day for 33 years.
 Forensic history is absent.

15. Socioeconomic history
 He lives in rural area, in a tin shed house.
 No sanitary latrines in it.
 He drinks from tubewell water.
 He is the only earning member of family. As he is
now jobless due to physical illness, he depends on
cooperation of relatives regarding livelihood.
Monthly expenditure of family is less then 5000 tk.

16. Drug & treatment history
 He couldn’t show any document or mention name of
drugs. During the time of stroke he took some
medication for few days, prescribed by a registered
physician. He also got treatment by traditional
healer.

17. Psychiatric history & personality
 No history of psychiatric illness, abnormal behavior.
 Patient’s prevalent mood & personality trait was
normal.

18. General examination
 Appearance: Ill looking, anxious, emaciated patient with
kyphosis.
 Body built: Tall stature, lean & thin.
 Nutrition: Height: 6 ft 1 inch, weight: 58 kg, BMI: 16.87
kg/m2
 Co-operation: Patient was well cooperative, rapport
established & maintained.
 Decubitus: on choice.
 Anemia: present (+)
 Jaundice: absent
 Cyanosis: absent
 Clubbing: absent

19. G/E Continue…
 Koilonychia: absent
 Leukonychia: absent
 Edema: absent
 Dehydration: absent
 Pulse: 84/min
 Blood pressure: 160/90 mmHg
 Temperature: normal
 Respiratory rate: 16/min
 Lymph node: not enlarged
 Thyroid: not enlarged.

20. G/E Continue…
 Other findings: scar mark on right leg, foot & toes of
burn & repeated traumatic injury.
 Right great toe is partially amputated & swelled by
fibrosis with bizarre figure. Nail of other toes of both
limbs show evidence of onychomycosis.
 A whitish patchy circular lesion measuring 1.5 cm x
1.5 cm at the center of the lower lip with irregular
margin, smooth surface & soft base. Sensation is
intact.

21. Systemic examination
Neurological examination
 Higher psychic functions:
- Appearance: a middle aged man, grey complexion
with anxious looking, lying in bed. Wearing shirt &
lungi which in socio-culturally & seasonally
acceptable. Kempt & combed.
- Behavior: normal. No oddity of motor or social
behavior.
- Alert & consciousness: patient is well alert &
conscious. GCS: E=4, V=5, M=6, total 15 out of 15.

22. N/E Continue…
- memory: immediate & recent memory was intact.
Remote memory was slightly impaired as he needed
help of wife to recall various remote issues.
- Intelligence: average
- Orientation: Oriented to time , place & person.
- Emotional state: mood euthymic & reactivity was
present.
- Hallucination: absent
- Delusion: absent
- Speech: relevant. Slightly slurred. Volume, rhythm,
rate & tone was normal.

23. N/E Continue…
Limb Bulk of
muscle
Tone of
muscle
Power of
muscle
Rt upper Reduced Hypotonic 3/5
Rt lower Normal Hypertonic 4/5
Lt upper Normal Normal 5/5
Lt lower Normal Normal 5/5
Motor functions:

24. N/E Continue…
- Fasciculation: absent
- Involuntary movement: absent
- Co-ordination test: intact
- Gait & posture: hemiplegic with walking aid.
• Reflexes:
 Superficial
- Planter reflex: equivocal at both side.
- Abdominal reflex: impaired on right side.
- Corneal reflex: intact

25. N/E Continue…
 Deep reflexes
• Clonus: absent
Side Biceps Tricep
s
Supin
ator
Knee Ankle
Right Absent Absent Absent Absent Normal
Left Normal Normal Normal Normal Normal

26. N/E Continue…
 Sensory functions
 Signs of meningeal irritation: absent
Modality Right side Left side
Pain lost Intact
Touch lost Intact
Temperature lost Intact
Vibration lost Intact
Position lost Intact
Tactile lost Intact

27. N/E Continue…
 Cranial nerves examination:
- Olfactory: intact
- Optic nerve:
Acuity of vision: 6/6 at both eyes
Field of vision: NAD
Color vision: normal
Light reflexes: normal
Fundoscopy: not done.
- oculomotor+trochlear+abducent: intact

28. N/E Continue…
- Trigeminal nerve: intact
- Facial nerve: intact
- Vestibulo-cochlear nerve:
Hall pike test: negative
Rinne’s test: AC>BC
Weber’s test: equal to the both ears
- Glossopharyngeal & vagus: intact
- Accessory & hypoglossal nerve also intact

29. S/E Continue
 Loco-motor system
- Bones: kyphosis of bony thorax
- Joints: tender & limitation of movements in the right
shoulder joint & scapula
- Spine: kyphosis, no swelling, non tender, movement
restricted. Schober’s test couldn’t be done.
- No sign’s of nerve root compression

30. S/E Continue
 Cardiovascular examination: normal findings
 Respiratory examination: normal findings
 GIT examination: normal findings
 Genito-urinary examination: normal findings
 Endocrine system examination: normal findings

31. Salient feature
 Mr. Syed Ali, 45 years old, married, father of two
children, jobless, previously lived in Kuwait,
kyphotic, under nutritioned , non diabetic,
hypertensive, anemic, smoker, from rural area of
Sunamgonj, came to SOMCH with the complaints of-
weakness of right side of the body for 5 months,
loss of sensation of right side of the body for 5
months, vertigo & blurring of vision for 5 days. He
smokes 15 sticks/day for 33 years means 24.75
pack year,

32.  He was alert & conscious, oriented to time, place &
person, remote memory slightly impaired, speech
slightly slurred. Bulk, tone, power of the muscle &
reflexes of right upper limb reduced or diminished
while right sided knee reflex was absent & ankle was
normal with hemi sensory loss. Both planter were
equivocal. Cranial nerve examinations revealed no
abnormality, limitation of movements of right
shoulder joints & spines as well. Schober’s test
couldn’t be done. Other systemic examinations also
revealed normal findings.

33. Provisional Diagnosis
???

34. Provisional diagnosis
 Central Thalamic Post-Stroke Syndrome

35. D/D
 Middle cerebral artery syndrome
 Syringomyelia

36. Central thalamic post stroke syndrome
 Points in favor-
- H/O stroke
- Weakness or paralysis of
the affected limbs
- Loss of sense of all
modalities especially
position sense to the
affected limbs.
- Mild to moderate pain on
affected limbs.
• Points against:
- Wasting of muscles of
right upper limb.
- Tonicity of the muscle is
not increased.
- Jerks are absent or
normal on the affected
limbs.

37. MCA syndrome
 Points in favor:
- weakness of the contra
lateral upper and lower
extremities
- Sensory loss of the contra
lateral face, arm and leg.
- Speech impairments
• Points against:
- No paresis or plegia in
contralateral face
- No ataxia
- No contralateral
homonymous
hemianopia

38. Syringomyelia
 Points in favor:
- Muscle tone and power is
diminished at RUL
- Reflexes are also
diminished at RUL
- Wasting of muscle of
RUL
- Patient is kyphotic
• Points against:
- General hemi sensory
loss, not dissociated in
arms, shoulder or neck
- Wasting of muscle may
be due to disuse atrophy

39. Investigation
Done: on 22.03.19
• Full Blood Count:
 ESR 27 mm in 1st hour
 WBC 9600/cumm, neutrophil 63%
 RBC 3.91 x 106/cumm
 Hb 10.0 gm/dl
• s. electrolyte: Na+ 142.8, K+ 3.06 , Cl-
109.8mmol/l
• s. creatinine 1.0
• CT scan of Brain: bilateral cerebral infarct

40. Investigation
 Report pending: given on 24.03.19
1. X-ray of cervical spine & right shoulder joint both
view.
2. Blood for VDRL, Anti ACV, HBsAg
 Plan:
1. MRI of brain & spine
2. Angiogram of the brain
3. Screening for bleeding & clotting disorder

41.  So, my diagnosis is central thalamic post stroke
syndrome.
 Other name is-
- Dejerine-Roussy syndrome
- Thalamic pain syndrome

42. Treatment
 Got:
- Tab. Aspirin 75 mg, 0+1+0
- Tab. Atorvastatin 20 mg, 0+0+1
- Tab. Losartan K 50 mg, 0+0+1
- Tab. Omeprazole 20 mg, 1+0+1
- Tab. Cinnarizine 15 mg 1+1+1
- Tab. Domperidon 10 mg 1+1+1
- Syp. KT, 1 tsf BD

43. Treatment
 Plan to add or may be given:
 Administration of opioids: Although effective, the relief lasts
only for 4-24hrs; as a result, they pose a high risk for
addiction
 Tri cyclic antidepressants and selective serotonin reuptake
inhibitors (SSRI) antidepressants are effective for short
durations
 Use of anticonvulsants.
 Topical local anaesthetic patches
 Physiotherapy
 Stimulation treatment: It involves stimulating the thalamus
and spinal cord through the implantation of electrodes. This
procedure is under study.

44. Prognosis
 The prognosis of Thalamic Syndrome depends on the
‘pain severity’ experienced by the individual. The
prognosis also depends on the extent of the brain
stroke.
 The pain can persist throughout the remainder of life
and may need to be managed with a combination of
pain medications and therapies.

45. Prevention is better than cure
 Managing the risk factors, such as hypertension and
heart problems, may help minimize susceptibility to
the condition.
 This may be achieved by bringing about certain
lifestyle modification and the use of suitable
medications.

46. THANK YOU