Frolaine Diclihon 05-10-20

BSRT-2
SCORE:46/50
Ischemic Stroke CONTENT: 22/25 ORGANIZATION: 15/15 MECHANICS: 9/10
COMMENTS: The paper is generally good, however, since ischemic stroke is well
A. Patient Information studied, I expected more from the discussion portion i.e. Ischemic Penumbra,
prognostication scoring etc.
This is a case of a 66 years old male that was rushed to the ED due to sudden onset of left-
sided weakness.

History of present illness:

30mins. PTA, the patient is at his house when suddenly he experienced left sided weakness,
slurred speech and facial weakness. 911 was called and the patient was transported to the ED by the
emergency medical service (EMS). Other pertinent negatives?

Past medical history:

The patient has hypertension, no known medical or food allergies

Social and personal history

The patient was divorced twice and currently resides with his male partner, has 2 daughters
and 1 son and his ex-wife is a retired teacher. The patient smokes 2 packs cigarettes/day and drink 2
bottles of wine.

B. Clinical Finding

Physical examination:

Vital signs: Temperature 99.2f oral, Heart rate70 bpm, Blood pressure 110/70 mm Hg, Respiratory
rate 24 bpm, O2 saturation 99%, Height 170 cm and Weight 95.3 kg.

General: Overweight, orally intubated on mechanical ventilation and in no acute distress.

HEENT: Pupils 2mm and equal, orally intubated and bilateral scleral edema

Chest: Bilateral expiratory wheezes, copious yellow secretions

Skin: warm and dry

Extremities: Upper extremities are warm, no edema noted, left radial artery, right forearm peripheral
IV and right femoral sheath.

Musculoskeletal: Right upper extremity (5/5), left upper extremity (1/5), right lower extremity (4/5)
and left lower extremity (1/5).

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Neurological: Richmond Agitation Sedation Scale (-1), follows command to right side only,
moderate sensory loss to left side, partial extinction to the left, left facial weakness, visual fields intact
and Glasgow Coma Scale (14).

C. Diagnostic Assessment

Computed tomographic imaging was completed within 26 mins of the patient’s arrival and
results were relevant because of the presence of dense right MCA and slight loss of gray- white matter
distinction that is highly predictive of stroke. Laboratory were tested as well a chest radiograph,
electrocardiogram and cerebral angiogram post IV tPA.

Diagnosis:

Based on the findings the patient has ischemic stroke- right medial cerebral artery and addition
to the diagnoses the patient has respiratory failure secondary to COPD exacerbation

D. Therapeutics, Patient Outcome and Follow-up

Plan specific to stroke care-

 repeat nonconstract computed tomography and monitor neurological status

 Three percent (3%) normal saline at 50 ml/hr

Suggestive of the use of hypertonic saline is safe and at least as effective in managing increased
intracranial pressure.

For respiratory care:

 Increase frequency of bronchodilator therapy every 4 hrs

 Methylprednisolone sodium succinate 60 mg IV push every 6 hrs

 CT scan results showed worsening of right MCA infarct with increasing ischemic edema. The
hyponatremia was corrected but no effect on the cerebral edema was realized with the
treatment of hypertonic saline. For the respiratory stand point, the patient showed clinical signs
of improvement after initiation of treatment for COPD including wheezing and fever.

Reference:
Warren,M.,& Ruppert S.D.(2011).Ischemic Middle Cerebral Artery. Critical care

quarterly,vol.34(isssue3),p218226.Retrievedfromjournals.lww.com/ccnq/Abstract/2011/0
700/Ischemic_Middle_Cerebral_Artery_Stroke_A_Case.8.aspx
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Epidemiology

Ischemic stroke is by far most common kind of stroke, accounting for about 88 % of all stroke. Stroke
can affect people with all ages, including children. Some factors put certain people at risk of stroke or
death from stroke. These include:

 Race/ ethnicity: Mostly common among African- American. Although, Hispanic Americans and
American Indian/Alaska Natives are at greater risk than white Americans for having stroke but
less risk than African American.
 Age: People who are older (60 or more years old) and the risk of stroke increase with age
 Gender: Men are more likely to have a stroke than women

Pathology

The MCA is the largest branch of the carotid artery and is most common artery occluded in a
stroke. MCA supplies blood to part of the frontal as well as the lateral section of the parietal and
temporal lobes. These regions of the brain control the primary motor and sensory areas of the face,
throat, hand, arm including the dominant hemisphere.

An ischemic stroke involves the acute occlusion of one of the intracranial vessels that result in a
reduction in blood flow to the affected portion of the brain. The etiology of an acute occlusion includes
cardioembolism and artery to artery embolism. Occlusion can arise secondary to thrombus formation
on atherosclerosis on any diseased vessel. Reduction of blood flow depend on the size and site of the
occlusion as well as the collateral blood flow available to the affected portion of the brain. In the
presence of no cerebral blood flow to the area, tissue death occur within 10 mins. Cell death after
arterial occlusion evolves along 2 different pathways, necrosis and apoptosis. The necrosis cell
starvation resulting in decreased glucose and energy production. Loss of energy production leads to
dysfunction of membrane ion pumps and cellular depolarization causing flux of sodium and calcium into
the cell. The cellular depolarization triggers postsynaptic glutamine receptors which further enhance
calcium influx into the cells. The influx of calcium leads to neurotoxicity. Cell suicide or apoptosis also
occurs as a result of the cell starvation, mitochondrial damage and the influx of cellular calcium.

Signs and symptoms:

- left sided weakness

- slurred speech

- facial weakness

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The patient respiratory symptoms occurs because there is a bronchial inflammation and mucous
plugging that cause the reduction of airflow in and out of his lungs leading to COPD. With the patient
that have smoking history have great risk because it causes damage to the blood vessels through the
body.

Diagnostics

 Laboratory:
ABG results revealed a respiratory acidosis
 CT of the head: Dense right medial cerebral artery (MCA) and possible early obscuration of
the gray- white interface in the anterior right temporal lobe consistent with right MCA stroke.
 Cerebral angiogram post IV tPA: Endovascular manipulation with penumbra and MERCI
devices with no recanalization and persistent right M1 occlusion.
 Chest radiograph: Bilateral atelectasis
 Electrocardiogram: Normal rhythm

Treatment

For stroke care;

 Three percent (3%) normal saline at 50 ml/hr

- Cerebral edema is common in large MCA infarcts so suggestive of the use of hypertonic saline is
safe and at least as effective in managing increased intracranial pressure.

 repeat nonconstract computed tomography and monitor neurological status

- The patient had a large MCA infarct with noted penumbra ischemia that could not be
revascularized. Close monitoring for neurological deterioration was warranted because of
increased risk of development of malignant MCA infarction.

For respiratory care;

 Increase frequency of bronchodilator therapy every 4 hrs

- The patient had smoking history and was noted to have bilateral wheezes and copious yellow
secretions, so diagnosis of COPD exacerbation was made. Since the patient continue to have
bilateral wheezing after receiving therapy every 6 hrs it frequency was increased to every 4 hrs.

 Methylprednisolone sodium succinate 60 mg IV push every 6 hrs

 Piperacillin/tazobactam 3.375 grams IV piggy back every 6 hrs

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Reference:

Treadwell SD, Thanva B. Malignant middle cerebral artery (MCA) infarction: pathophysiology,

diagnosis, and management. Postgrad Med J. 2009;86:235-242.

Warren,M.,& Ruppert S.D.(2011).Ischemic Middle Cerebral Artery. Critical care

quarterly,vol.34(isssue3),p218226.Retrievedfromjournals.lww.com/ccnq/Abstract/2011/0

700/Ischemic_Middle_Cerebral_Artery_Stroke_A_Case.8.aspx

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