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> CASE 2 Atrioventricular Malformation

David K was driving through a busy southern California intersection when his left arm and leg stopped working. He glided to the side of the road, partially blocking traffic. Realizing something was wrong, he called 911 and reported, “I’m at Plummer and Reseda,” but the operator kept asking him to repeat himself. His memories of the event fade in and out; he unlocked his car and put a note on his windshield to call for help. When the paramedics arrived, they found him slumped over the steering wheel and asked his name, but he was only able to point to his wallet in response to their questions. His speech returned during the ambulance ride; he spent the entire time trying to convince them to stop for hamburgers. Once at the local hospital, he was transported to CT scan to determine the cause of his acute neurologic decline. Clinical findings were consistent with a cerebral vascular accident. Test results were positive for ischemic rather than hemorrhagic onset, qualifying him for the drug t-PA (tissue plasmin activator).

David K was an active man in his early 50s, working as a software engineer. His true passion, however, was his volunteer work. Thirty years of running around soccer fields as a referee gave him strong legs and excellent cardiovascular fitness. This high level of fitness may be the reason his physician neglected to follow up with a cardiology consultation when he found an abnormal heart rate (arrhythmia) during a routine check-up six months prior. Atrial fibrillation causes inefficient blood circulation, subsequent pooling, and increased risk of clot development. Released clots impede circulation and cause tissue damage through ischemia. David had several large clots (thrombi), which settled in his right middle and posterior cerebral arteries. The t-PA is most effective when delivered during the first few hours after ischemic stroke, and probably saved David's life. However, the neurologic damage was severe, and he remained unable to control motion of his left side. Four days later, David developed a thrombus in his right calf, underwent vascular surgery, and was placed on temporary bed rest.

A dislodged thrombus (thromboembolism) can travel up to the heart or brain and cause serious damage, including death. This prolonged period of inactivity cost him dearly, as he developed severe tightness in his knee, which delayed his recovery and ability to participate in therapy. David remembers fighting for every week of rehabilitation, constantly being told that there was little chance of improving. His course of care was typical, even better than the average, as he had insurance and spent six weeks in an acute care hospital with several weeks in a CARF (Commission on Accreditation of Rehabilitation Facilities)–accredited interprofessional inpatient rehabilitation unit. This unit provided hours of daily intensive rehabilitation therapy, with coordination by a physiatrist (physician specializing in physical medicine and rehabilitation). The program included occupational, physical, speech, and recreation therapy; neuropsychiatric evaluation; social work; ...

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