Stroke
Petro Zaroukian, MD
Resident Physician
Casa Colina Hospital and Centers for Healthcare
Pomona, California, United States
Brian Khin, DO
PM&R Resident
Casa Colina
Arcadia, California, United States
Cameron Widhalm, DO
PM&R resident
Casa Colina
Pomona, California, United States
Brian Vu, MD
resident physician
Casa Colina Hospital
Chino Hills, California, United States
Emmanuel Villalpando, MD
resident physician
Casa Colina Hospital
Pomona, California, United States
Hunter Goldsmith, MD
PM&R Resident
Casa Colina
Pomona, California, United States
Petro Zaroukian, MD
Resident Physician
Casa Colina Hospital and Centers for Healthcare
Pomona, California, United States
The patient was found down with a rightward gaze and left facial droop. CT head confirmed a right basal ganglia hemorrhage, attributed to hypertensive emergency with a systolic blood pressure greater than 200mmHg. On admission to acute rehabilitation, he was noted to previously be fully independent in all acts of daily living, employment as an administrator in marketing and management of spouse’s business. During his rehabilitation course, he reported no cognitive changes and denied mood changes. Initial speech therapy evaluations were unremarkable. However, his wife noted slowed responses, increased seriousness, irritability, and a generally different demeanor. This prompted further speech therapy and neuropsychology evaluations that revealed markedly slow processing speed, impaired memory encoding, delayed recall, working memory deficits, poor spatial planning, poor organization, inattention to detail, set-shifting deficits, difficulty with abstract and figurative material, and diminished visual estimation and planning. He received SLUMS score 16/30, consistent with moderate cognitive impairment.
Discussions:
This case illustrates how high premorbid functioning may obscure post-stroke cognitive deficits, which became apparent only through comprehensive speech-language and neuropsychological assessments. Studies demonstrate that even among stroke survivors with excellent physical recovery (modified Rankin Scale 0-1), a majority demonstrate cognitive impairment on detailed testing, most notably in executive and attentional domains. As described in our case, the patient’s family played a large role in identifying deviations from cognitive and behavioral baseline. Moreover, this highlights the importance of early involvement of speech therapy and neuropsychology to facilitate timely identification of deficits and to optimize rehabilitation outcomes. High cognitive reserve can mask post-stroke cognitive deficits undetected by brief screening. Comprehensive neuropsychological assessment, supplemented by family input, is critical to guide rehabilitation, inform caregivers, and ensure safe return to complex roles.
Conclusions:
