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> CASE 10 Hemorrhagic Stroke

Dr. T. stood in the den, pointing with his cane to the tin soldier collection. Walking was slow since the hemorrhagic stroke, due to the residual weakness in his trunk and right side. His voice soft and his right hand stiff and shaky from nearly two hours of speaking, he carefully pointed out the impressive collection of tiny figurines, displayed in cases of his own design and construction.

The doctor and his wife of 54 years were just getting ready for bed that night, nearly two years ago, when he collapsed, unresponsive. Paramedics took them to UCLA Medical Center, where Dr. T. remained active as a director, researcher, and educator. During the first few hours, as his wife and their children waited, he underwent first a CT to rule out trauma or a tumor, and then an MRI to establish the amount of tissue damage. The team consulted and decided an emergency craniotomy was indicated, to reduce cerebral damage from the edema. In the days that followed, he began to move his left side, and he was able to take his wife's hand, but his right arm and leg remained weak, and his speech was limited. He could speak haltingly, using only a couple words at a time for most communication except for one topic.

When his health care team came to discuss his plan of care, he resorted to old, deeply ingrained communication skills honed over decades as a physician and fellow team member. He remained fluent in medical jargon and was able to discuss and participate in medical decisions. Over the years, he had treated thousands of patients, and nearly 150 new patients each month, in his role overseeing coronary care. This exposure proved valuable during his post-stroke recovery. “Phlegmasia cerulea dolens,” he stated, slowly for emphasis. He had recalled the words and was able to say them clearly and distinctly to his physicians. It was a rare and potentially fatal condition he had seen in patients who reported horrific pain. “My cardiologist immediately took action and started treatment,” he recalls. “I recognized the symptoms in myself, particularly the pain, worse than any I’d ever experienced, worse than any fractures, or even passing a kidney stone.”

Phlegmasia cerulean dolens is a rare type of vein thrombosis involving deep veins and their tributaries. Severe, acute cyanosis and swelling is due to the nearly complete blockage of the venous system, creating the blue color and pain that give the condition its name. It is potentially fatal, with a high risk of pulmonary embolism and, when capillaries are blocked, even gangrene. Treatment of the condition consists of anticoagulation and surgical thrombectomy. Dr. T. responded to the treatment and was fortunate to have no gangrene or permanent damage to his legs from the condition. He made steady progress after the medical team treated his thrombosis, and moved to the inpatient rehabilitation unit for ongoing care. This ...

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