FIRST CLINICAL CASE STUDY 1

Acute Right Middle Cerebral Artery Cerebrovascular Accident

Joida Mae Esper I. Canono 22030085

ENP 110 Nursing Practicum II

Clinical Instructor Robbi Martson

February 6, 2023
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Acute Right MCA CVA

History of Present Illness

Mr. Frank J. M. is an 89-year-old, male patient who was admitted to the hospital, arrived

at the emergency room on January 5, 2023 after being discovered on the floor by her daughter in

law for about two days following a fall (from the toilet) in which he hit his neck. The patient had

been crawling on the floor and had not been drinking or eating, and he had been incontinent for

two days before being admitted. The patient was very confused and difficult to understand in the

emergency room. It was also noticed that the left side of his body was twitching. partial seizures;

patient needed to see 02 in ED; After performing a head CT, it was discovered that the right

parietal lobe had a minor hypodensity that was probably a tiny non-hemorrhagic infarct.

Recommend performing an MRI to check for any underlying mass lesions. On January 11, a

brain MRI was performed; it revealed no acute abnormalities. Right frontal lobe hemorrhagic

older infarct consistent with the patient's past. Additionally, there were tiny abnormal proteins

deposits everywhere. On January 10, the patient experienced two partial seizures and was

severely edematous in his upper and lower extremities. After completing an ultrasound on his

left arm, it revealed a thrombus in the basilic vein. However, a second ultrasound of the left arm

revealed no DVT. Pt. moved to the rehab unit on January 27 at 23:00. The patient was previously

dependent on ADLs and lADLs; his family is unwilling to take him home; and he is unable to

live on his own. The patient's ultimate aim is to be transferred to Davey Home, however, he will

first need to undergo stroke rehabilitation.

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Past Medical History

1. Atrial Fibrillation

2. Hypertension

3. BPH

4. Heart Failure, unknown EF

5. Gout

6. Chronic Kidney Disease with baseline creatinine 157 in April 2022

7. Previous alcohol use disorder, in remission

8. Left arm pain NYD.

Social History

 Support system – from home alone with highly supportive children. Previously

independent with ADLs and IADLs. No longer drink alcohol, no smoker, no recreational

drug use.

Medical Diagnosis:

Acute Right MCA CVA, seizure

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Pathophysiology

The middle cerebral artery (MCA) is the most common artery involved in acute stroke. It

branches directly from the internal carotid artery and consists of four main branches, M1, M2,

M3, and M4 (Nogles, 2022).

MCA strokes occur when the MCA is obstructed or torn, interrupting blood flow to the

MCA's region. The internal carotid arteries' MCA is their largest branch. It transports blood,

which is rich in nutrients and oxygen, to several the brain's most important regions. Brain

function is inhibited, and brain cells are killed when there is insufficient blood flow.

The symptom that the patient manifested when he arrived at the triage were confusion,

left sided weakness, twitching at left side of his body, left arm edema, partial seizures and bp on

lower side. Head CT shows small area of cortical subcortical hypodensity right parietal lobe

representing a small subacute infarct. Brain MRI shows theres hemorrhage noted in the previous

infarct to the right frontal lobe with some tiny foci hemosiderin deposits elsewhere, infarct right

frontal lobe as previously seen. These have an impact on the side of the body opposite the artery.

As a result, symptoms of a stroke in the right MCA appear on the left side of the body. MCA

strokes are frequent and have well-known symptoms. Numbness after stroke is a common

secondary effect that causes loss of sensation in some of the affected areas. It can be

accompanied by other sensory issues such as tingling sensations and even hypersensitivity. The

area of the brain affected by stroke determines the secondary effects that occur. For example, if

the area of the brain that regulates sensation is affected, it may result in impaired sensation like

numbness. Regarding post-stroke numbness, two areas of the brain deserve a deeper look: the

thalamus and occipital lobe. The thalamus is responsible for interpreting 98% of all sensory
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input. In a related manner, the occipital lobe differentiates this input from the five senses,

including touch. Therefore, post-stroke numbness is commonly seen after a thalamic stroke or

occipital lobe stroke because these areas of the brain play a large role in sensory function MCA

strokes are frequently brought on by blood clots that originate in the carotid artery or heart. As a

result, areas that get blood from the MCA may experience blood, oxygen, and nutrition loss that

can harm the brain and impede function.

Following MCA stroke, rehabilitation can consist of many treatments and therapies to

help regain lost function. This can include physical, occupational, speech, and cognitive therapy

to help address and improve all aspects of daily life. One major goal for survivors of MCA stroke

is regaining lost physical function. This will be the focus of physical and occupational therapy to

enhance performance of daily activities. In addition to in-person sessions, the therapy team will

provide with exercises to perform by patient’s own to help maximize his recovery.
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Reference:

Nogles, T. E., & Galuska, M. A. (2022, May 8). Middle cerebral artery stroke - statpearls –

NCBI bookshelf. MCA Stroke. Retrieved February 6, 2023, from

https://www.ncbi.nlm.nih.gov/books/NBK556132/