Age: 30.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Activated partial thromboplastin time normal, Angiogram cerebral normal, Anticoagulant therapy, Aphasia, Atrial septal defect
Clinical narrative: 9/2/21: The patient is a 30 year old female who presents to the ED for evaluation of strokelike symptoms.  At approximately 11 PM tonight the patient reports having sudden onset of confusion and difficulty speaking.  Patient and family explain she is having difficulty getting words out and has slurred speech.  She also reports experiencing left-sided weakness and numbness.  A short while after also started to experience dizziness and if she tries to focus on something she sees double.  Denies any associated headache or neck pain.  No chest pain or dyspnea.  No fever or recent illness.  No recent trauma.  Patient states she received the J&J vaccine 2 days ago, denies any other new medications.  Denies similar episode 30-year-old acute female here for evaluation of strokelike symptoms.  Patient evaluated on arrival as a stroke alert.  Last known normal was approximately 11 PM.  Neurologic deficits include slurred speech, left-sided numbness and weakness, dizziness and double vision.  On exam, the patient is noted to have decreased sensation to the left face/arm/leg as well as decreased grip strength and left lower extremity weakness.  NIHSS 4.  Patient transferred emergently to CT which returned negative for acute intracranial hemorrhage.  Case discussed with teleneurology who also evaluated patient.  Decision made to treat with TPA.  Patient was monitored closely post TPA infusion and on serial neurologic exams was noted to have significant improvement in her speech, sensory deficits and strength testing.  NIHSS improved to 2.  Toxic/metabolic work-up overall returned reassuring.  Patient to be admitted to ICU for further care and evaluation  9/4/21 Cardiology: 1.  Acute neurological event resolving after TPA administration with subsequent large PFO found on transthoracic echocardiogram.  Treatment recommendations regarding her PFO ultimately revolve upon what neurology feels etiology of her neurologic event was.  If it was felt it was ischemic in nature treatment options include aspirin and Plavix for 3 weeks followed by a long-term low-dose aspirin versus PFO closure.  Numerous randomized trials PFO closures only shown to be beneficial in patients with minimal atherosclerotic risk factors, large PFO's and positive neuroimaging.  With a negative diffusion-weighted MRI I do not believe there is any indication for closure.  If it is felt that her neurologic event is a complication of the Covid vaccine no further management of her PFO is indicated.  If it is felt that it was a true ischemic event despite her negative diffusion-weighted MRI then would recommend dual antiplatelet therapy for 3 weeks followed by low-dose aspirin indefinitely.  Appreciate the opportunity to participate in patient's care. Please call with any questions.  9/4/21: DISCHARGE  9/5/21: READMIT 30-year-old female with depression, anxiety, and GERD presents to the ED with recurrent neurological symptoms.  She reports the onset 1 hour prior to arrival of difficulty speaking, left-sided weakness.   She had a similar presentation 3 days ago and actually received intravenous TPA with improvement in her symptoms.  Her evaluation included a normal head CT.  She had an MRI/MRA of the head, MRA neck, and MRV, all of which were normal.  9/5/21 ICU: This is a 30 year old female who was recently hospitalized for expressive aphasia and left sided weakness several days after after receiving the J&J COVID-19 vaccine, and subsequently was given TPA and sent to the ICU.  MRI of the brain, MRA of the head/neck, and MRV of the head were unremarkable at that time. TTE demonstrated a patent foramen ovale, however cardiology was consulted and there was no indication for closure.  Patient symptoms returned to normal and she was discharged from the hospital on 9/4/2021.    She returned to the hospital today complaining of aphasia and left-sided weakness. Teleneurology was consulted in the ED and recommended imaging as well as admission to observation for possible LP. MRI brain and MRV head were negative for acute intracranial abnormality; however, there were several small punctate foci of increased hyperintensity within the white matter which were nonspecific findings.   On presentation, she is afebrile with temperature 98.5 °F, heart rate ranged 80-132 bpm, RR 16, BP 147/86 mmHg, SPO2 100% on room air. On exam she is laying flat on her back in bed, no acute distress, pleasant.  Flat affect.  Tired appearing.  Alert and oriented x3.  CN II through XII grossly intact bilaterally.  Strength 5/5 in all extremities.  Speech is slowed but not dysarthric.  Sensation is intact throughout except for mild numbness in the lateral aspect of her left leg.  Heart is regular rate and rhythm, distal extremities are warm and well perfused.  Lungs are clear to auscultation, breathing comfortably on room air.  Abdomen is soft, bowel sounds present, nondistended.  9/5/21 Neurology: Impression: Transient speech change and L sided weakness/numbness   Recommendations: 1) LP - cell count differential protein glucose cytology cultures, lyme ACE, VDRL 2) EEG 3) Check ANA, SSA/SSB, Complement, Anti-TPO, autoimmune panel 4) Can be discharged home if initial results negative with close outpatient follow up.  9/6/21 Hospitalist: Radiology call - showing "moderate to large epidural hematoma within the posterior epidural space with hemorrhagic fluid seen from the level of L1 extending caudally to the L5 level with the most significant portion of the hemorrhage located at L2-L3 causing severe central canal stenosis at L2-L3."  9/6/21: The patient is a pleasant 30 y.o female with severe back pain and left leg paresthesias with a large epidural hematoma from L1 to L5 with severe stenosis at L2/3 causing lumbar radiculopathy.  I discussed with her the options including conservative care versus surgical intervention. Given the patients significant symptoms with severe stenosis at L2/3, I recommended surgical intervention which would entail a L2 and L3 laminectomy and evacuation of epidural hematoma.  I discussed with her the potential risk, complications and lack of guarantees.  Pt wishes to proceed with surgery.  The Intensivist discussed with Hematology who agrees that the tPA should be out of her system.  Pt had PT, PTT and INR today that are normal.  The LP was performed at the L2/3 level and I may need to place a patch and glue if there is any CSF detected.  We will proceed with surgery urgently.