Friday, October 08, 2010

When a stroke's not a stroke.

When is a stroke not a stroke?

Well, when it's...not a stroke, Eisenstein.

One of the interesting things about the human brain and body is that, when you've had something go very wrong indeed in your head, that wrong thing can be reactivated by things going wrong in your body. It can even be made worse.

Let's take a typical case: your average Little Old Lady In No Acute Distress (LOLNAD) who had a stroke, say, ten years ago, that left her with a little residual left-sided weakness. Other than having to use a cane to keep from tipping over unexpectedly, she's dandy. She lives in one of those poncy-schwantzy apartments with a day nurse who comes in to help give her meds and an aide that stays overnight.

One morning, the aide notices that in addition to being more weak on the left side, Granny LOL is confused and can't talk very well. She's having difficulty following commands and seems really sleepy and irritable. The aide, being a bright person, calls 911.

The ambulance arrives and whisks Granny LOL to the nearest emergency department, where she has a thorough stroke workup: chemistries, urinalysis, a CT scan of her head to rule out a bleed, and a general exam. Everything's negative....except the urine. It's hot. She's got a UTI.

So she's given a dose of antibiotics and sent over to me at Sunnydale, where she gets an MRI to look for signs of new occlusive stroke. She also gets all the other tests and chicken-waving that are standard for our patients. At the end of the day, we discover...

...No stroke. Thank God. Just a UTI that's been allowed to grow (because most people can brew one without symptoms, and older folks are hit hard by them).

Why does this happen? Honestly, I don't know the technical explanation. I do know that in probably half the female patients I get who are over the age of 70, and about a third of the male patients that age, there's a urinary tract infection that's present. It's recognized that even a supposedly "asymptomatic" UTI can cause the sudden onset of confusion or a worsening of dementia. That same infection can cause what we call a reactivation of old stroke symptoms as well--sometimes to the point that the person's worse off than when they had the original stroke.

Moral of the story: If you have an elderly patient (or, for that matter, any patient) who suddenly manifests a worsening level of consciousness, do a UA while you're doing all the other stuff to rule out nastier things. It's a fair chance your person will have a positive dipstick, and antibiotics will vastly improve things.

8 comments:

Penny said...

Here's my theory: When my vascular-dementia-ridden Mother had a UTI, she would behave exactly the way the rest of us would LIKE to behave. The dementia took the filters away and allowed her to attempt to kick the world's ass for making her feel so poorly. The rest of us WOULD react the same way, were it not for those friggin' manners we got drilled into us as young-uns.

Crazed Nitwit said...

UTI is the first thing we check when one of our patients is getting loonier than normal. It scary how quickly a UTI can make an older person go down.

Just My 2¢ said...

Didn't know that. Thanks for the tip from an EMS type of guy... And thanks for getting back into the groove.

woolywoman said...

yup. had pts that suddenly were unable to walk: UTI. Suddenly nuts: UTI. Seizure: UTI. and so forth. Same in newborns for what its worth but they move quickly into sepsis like in an hour.

Moose said...

When I was 26 I had a sudden, severely painful headache followed by vision problems in one eye. My then-doctor diagnosed it as a stroke, solely on the basis of, "Well, you're fat." No CT scan (this was before MRIs were common), blood pressure was 100/40, no medications that might have been involved.

It took another Dr sending me to a neurologist to discover it was a "complicated migraine." I did have another about 6 months later, then never again.

On the flip side, I knew a doctor who did a urine dipstick for everything. I allegedly constantly had UTIs. Then I read in an ER-related journal [the kind with peer-reviewed published studies] how dipsticks can have up to a 40% false positive reading.

I dunno if that's still true; this was a good 5 yrs ago. I'd like to think the dipstick tests have gotten more accurate since then.

Jenn Jilks said...

Wise warnings. My brother took Dad to emerg the day of mom's funeral. They sent him home in the afternoon with undiagnosed UTI, still peeing on the floor in the middle of the night and demonstrating signs of delirium. I was pissed, if you'll excuse the pun. They attributed it to dementia from his brain tumour. No one warned us that it was a complication from radiation treatments Dad was getting.

Good post.

shrimplate said...

Easy to diagnose (pee in a cup) and easy to treat most of the time. A little Sulfa or more likely Levaquin and things are all better in a day or two, with maybe a run of IV fluids to move it along.

Anonymous said...

While stationed in Puerto Rico my wife suddenly developed dementia symptoms and I took her to base hospital and was told she had a stroke. They sent her to the civilian hospital in San Juan where they confirmed the stroke. The Navy medevaced her to Portsmith Naval Hospital in Virginia where the reaffirmed the stroke. This took place in a 3 week period. Right side was week, right half of face slack, slurred words when trying to talk, did not know who I was or where she was. Her daughter, a civilian nurse, arrived from Georgia. Shortly she noticed her mother's urine was very dark and cloudy and asked nurses about it. Up to then, no one had noticed the condition of her urine. (?? How ??) It was found that she had a bad Urine Tract Infection (UTI) and started her on antibiotics. Once the infection was under control, my wife suddenly was clear as a bell mentally and all physical symptoms were gone. For 4 weeks I had been told my wife had a stroke and basically there was little they could do when all along she had only an infection.

I starting checking with different medical personnel and it seems most nurses know a UTI can cause stroke like symptoms but most doctors I interviewed did not seem to know of this. How many other women, especially elderly women, have been misdiagnosed for this?

For the elderly women who start exhibiting signs of delirium make sure they are checked for UTI infection and anemia before the final word of stoke is decided on.