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A Pathophysiology- BN607 > Case study: Bary (Stroke) > Flashcards

Case study: Bary (Stroke) Flashcards

1
Q

Who is Barry?

A

Barry W, aged 64, was admitted to hospital and diagnosed with having suffered a stroke after he collapsed while crossing the street on his way to the hospital.

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2
Q

What was barry’s symptoms before his collapse?

A
  • Lethargy
  • Fatigue
  • Hearing impairment
  • Loss of appetite
  • “Funny turns”. Issues with coordination and motor control
  • Erratic behaviour
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3
Q

What was Barrys symptoms from his stroke?

A
  • Couldn’t speak/ slurred speech
  • Couldn’t move his arm
  • R) sided facial droop
  • Collapse
  • Difficulty hearing
  • Uncoordinated movements/ difficulty moving
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4
Q

What was barry’s GCS upon admission?

A

Glasgow Coma Scale (GCS): 10/15

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5
Q

What was barrys vitals upon admission?

A

BP: 185/110 mmHg
HR: 92 beats/min
RR: 30 breaths/min
O2 saturation: 100% on 2 L/min
BGL: 16.5 mmol/L

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6
Q

What are the general, modifiable risk factors of stroke?

A
  • Excessive alcohol consumption
  • Atherosclerosis or vascular disease
  • Certain drugs
  • DM
  • Hypertension
  • Hypercholesterolemia
  • Obesity
  • Smoking
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7
Q

What are the general, NON modifiable risk factors of stroke?

A
  • Older age
  • Family hx of CVA or MI
  • Male sex
  • Arterial abnormalities
  • Ethnic origin (African or asian)
  • Patent foraman oval
  • AF
  • Certain blood disorders
  • Previous CVA or TIA or MIA
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8
Q

What is barrys previous health hx?

A

A couple months prior, Barry had experienced a similar episode in which he was admitted to ED. Went back to normal.

About four years prior to that, Barry had a stroke affecting the left temporoparietal-occipital area of his brain and leaving him with right homonymous quadrantanopia (Loss of the the same quadrant of the visual field in each eye).

  • Hypertension (poorly controlled)
  • T2DM
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9
Q

What was barrys risk factors?

A
  • Advanced age
  • Hypertension
  • T2DM
  • Previous CVA/ TIA
  • Male sex
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10
Q

Why can the symptoms of stroke widley vary?

A

Signs and symptoms of stroke can be wide and varied, depending on the location of stroke.

Stroke should be considered in any patient presenting with an acute neurological deficit (focal or global) or altered level of consciousness.

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11
Q

What symptoms are more common in hemorrhagic strokes?

A

Nausea, vomiting, headache, and a sudden change in the patient’s level of consciousness are more common in hemorrhagic strokes.

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12
Q

What are general symptoms of CVA?

A
  • Numbness of the face, arm or leg- particularly if only one side of the body is affected
  • Difficulty seeing with one or both eyes
    difficulty with walking
  • Dizziness, imbalance, or uncoordinated movement
  • Facial droop or uneven appearance to the face uneven muscle strength in limbs

Although such symptoms can occur alone, they are more likely to occur in combination.

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13
Q

What does F.A.S.T stand for?

A
  • Face
  • Arms
  • Speech
  • Time of symptom onset / time to get help
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14
Q

When assessing “face” from FAST what should you ask?

A

Ask the person to smile.

  • Does one side of the face droop?
  • Does the face or eye look crooked?

A section of the face, usually only on one side, could droop and the patient may find it hard to move.

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15
Q

When assessing “arms” from FAST what should you ask?

A

Ask the person to raise both arms.

  • Does the person have difficulty lifting one or both arms?
  • Do one or both arms drift?
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16
Q

When assessing “speech” from FAST what should you ask?

A

Ask the person to speak or repeat a sentence.

  • Are the words slurred?
  • Is the person having difficulty speaking or unable to speak?
  • Does the person have a problem understanding you?
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17
Q

When assessing “time” from FAST what should you ask?

A

Establishing the time at which the patient was last without stroke symptoms, or last known to be normal, is especially critical when fibrinolytic therapy is an option. In some cases, this may be difficult and could require input from others regarding the onset of symptoms.

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18
Q

What are the two main kinds of CVAs?

A

ischemic and hemorrhagic

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19
Q

What is an ischemic CVA?

A

Ischemic: Narrowing or occlusion of cerebral arteries leading to tissue ischemia. Subsequent tissue infarction if perfuscion isn’t restored quickly.

Ischemic stroke caused either by thrombus or embolus.

Most common kind of stroke (80%-85%)

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20
Q

What is a hemorrhagic stroke?

A

Occurs when there is a rupture of the cerebral arteries, resulting in hemorrhage and hematoma formation within the surrounding tissues.

Hemorrhagic strokes lead to direct tissue damage from blood and tissue ischemia further downstream from the rupture.

Increase ICP. Can lead to brain swelling.

About 15% of strokes

The hypoxic tissue resorts to anaerobic metabolism and, if the blood supply is not restored, it eventually leads to cell death (infarction) and functional loss.

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21
Q

What kind of stroke did barry have?

A

Ischemic stroke.

Likely caused by a ‘shower of emboli’ obstructing blood supply to different regions of his brain.

The emboli most likely resulted in infarcts occurring over the course of several weeks.

The most probable explanation is that the emboli originated from an atherosclerotic plaque which was progressively breaking up.

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22
Q

For bary, what arteries were involved with his stroke?

A
  • Left middle cerebral artery
  • Left posterior cerebral artery
  • Posterior inferior cerebellar artery
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23
Q

In what brain tissue did barry have infarction?

A
  • Left temporal lobes
  • Left occipital lobes
  • Cerebellum
  • Brainstem
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24
Q

What nerves were involved in barry’s stroke?

A

Right cranial nerve V (Trigeminal)
Right cranial nerve VI (Abducens)
Right cranial nerve VII (Facial)
Some impact on cranial nerve X (Vagus)

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25
Q

Which of the following are categories on the GCS?

A
  • Motor response
  • Eye opening
  • Verbal response
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26
Q

What is the range of scores for the GCS?

A

3 - 15

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27
Q

Before starting a GCS assessment what is important to check?

A
  • Patient understands procedure
  • Ascertain the patient’s acuity of hearing
  • Whether the can speak English
  • Check any medical condition that may affect the accuracy (e.g., a previous stroke that is affecting the movement of the patient’s arms or eye defect)
  • Check the neurological observation chart for the GCS scale and previous result
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28
Q

What is eye opening assessed from?

A

1 - 4

29
Q

How to asses eye opening GCS?

A
  1. Check if the patient opens their eyes without the need to speak or to touch them.
  2. If the patient does not open their eyes, talk to them. Start with a normal volume and speak louder if necessary.
  3. If the patient does not open their eyes to speech, apply a pressure stimulus to see if you can illicit a response, generally in the following order:
    - Finger press
    - Trapezium squeeze
    - Suborbital pressure
  4. No response
30
Q

What is verbal response assed from?

A

1 - 5

31
Q

How to assess verbal response GCS?

A

Ask the patient a closed question, such as:
What’s your name/ date of birth?
What day is it?
Where are you?

Check the response against the scores for this category.

5: conversant with correct response(s)

4: conversant, but confused/incorrect responses or information

3: words, but disorganized, inappropriate or not coherent

2: no words, only sounds

1: none

32
Q

What is motor response assed from?

A

1 - 6

33
Q

How to assess motor response GCS?

A
  • Ask the patient to squeeze your hand, and then release.
  • Ask the patient to do thumbs up sign or high five.
  • If the patient is unable to complete the previous tasks, apply a pressure stimulus to the finger, trapezius or suborbital area and check the upper limb movement in relation to the location of the stimulus.

6: normal, obeys command

5: localized to pressure stimulus (attempt to remove stimulus)

4: normal flexion response to pressure stimulus

3: abnormal elbow flexion (across body with pronation)

2: elbow extension, straightening limbs

1: none

34
Q

What scans can you do when assessing CVA?

A

CT and MRI

35
Q

What is a CT scan?

A

The precise differences in density allowed by computerized tomography (CT) scans can clearly show tumors, strokes, or lesions in the brain area as altered densities.

These lighter or darker areas on the image can highlight a tumor or hematoma within the brain and skull area.

The speed and convenience of CT often allows for early detection of hemorrhage or ischemia.

36
Q

What is a MRI scan?

A

Barry eventually also underwent magnetic resonance imaging (MRI).

Below are the videos from Barry’s MRI scans- note the difference in density of brain tissue within the posterior regions of his brain (lighter appearing areas).

37
Q

What did barrys scans confirm?

A

Confirmed acute bilateral cerebellar infarcts

With brainstem involvement

Mature infarcts in the left occipital lobe and portions of the temporal lobe.

38
Q

What to asses in the Neurological assessment?

A
  • Visual field (peripheral vision)
  • Facial movement
  • Facial sensation
  • Corneal reflex
  • Leg movement (leg lift)
  • Arm movement (arm lift)
39
Q

During visual field (peripheral vision) assessment what was the response/observation

A

Barry had very limited peripheral vision on his right side in both eyes.

40
Q

During facial movement assessment what was the response/observation

A

Barry had limited movement on the right side of his face.

41
Q

During facial sensation assessment what was the response/observation

A

Barry had limited sensation in the right side of his face.

42
Q

During corneal reflex assessment what was the response/observation

A

Barry did NOT exhibit a corneal reflex with his right eye.

43
Q

During leg movement (leg lift) what was the response/observation

A

Barry could lift both his right and left legs, though there was apparent weakness in his right leg.

44
Q

During arm movement (arm lift) what was the response/observation

A

Barry had significant weakness is his right arm and was unable to lift it.

45
Q

Why are barrys impacts mostly on the right side of his body?

A

Bc he had an infarction of his LEFT cerebral hemisphere (Which controls the right side of the body).

And some of his RIGHT cranial nerves were affected.

46
Q

What are the affects of barrys stroke?

A
  • Dysarthria (difficulty speaking)
  • Dysphagia (Difficulty swallowing)
  • Truncal ataxia (Poor coordination & balance throughout the trunk leading to difficulty sitting upright or standing without support and unsteady gait.)
  • Hemiparesis
  • Poor short-term memory and difficulties with impulse control and cognitive flexibility. Severe visuospatial impairments (Associated to previous CVA)
47
Q

What are general complications from CVAs?

A

The complications of stroke are highly varied, depending on the regions of the brain impacted.

Speech disorders
- Aphasia
- Apraxia
- Dysarthria

Other
- Dysphagia
- Hemiparesis
- Visual disturbances
- Fatigue
- Depression

48
Q

What is aphasia? And what are the two kinds?

A

Problems with producing or understanding language.

Expressive aphasia is an inability to put thought into words (damage to Broca’s speech area).

Receptive aphasia is an inability to understand the spoken word (damage to Wernicke’s speech area).

49
Q

What is apraxia?

A

An inability to properly plan and sequence the movements required for speech, making it difficult for someone to correctly and consistently say what they want to

50
Q

What is Dysarthria?

A

is the disturbance of the muscular control of speech (this does not include speech disorders due to structural abnormalities, e.g. cleft palate). Cranial nerves that control the muscles of speech include the trigeminal nerve (V), the facial nerve (VII), the glossopharyngeal nerve (IX), the vagus nerve (X), and the hypoglossal nerve (XII).

51
Q

What is Dysphagia?

A

Dysphagia is a difficulty with swallowing which is another possible complication of stroke. Signs and symptoms may include:

  • Abnormal eating behaviour
  • Coughing or choking when eating/drinking
  • Weak cough - unable to cough effectively if an aspiration occurs
  • Wet gurgly voice
  • Swallowing apraxia
  • Difficulty chewing
  • Changes in respiratory pattern while feeding - inhalation during swallowing
52
Q

What is Hemiparesis?

A

The most common physical impairment is hemiparesis- a weakness or an inability to move on one side of the body.

Hemiparesis affects roughly 80 percent of stroke survivors and may affect muscles from the face to the feet. Those impacted may have trouble performing everyday activities such as eating, dressing, using the bathroom, and grabbing objects.

53
Q

What is hemianopia?

A

The loss of half of the visual field in an eye.

54
Q

What is homonymous hemianopia?

A

Barry exhibits right side homonymous hemianopia which affects his visual field (peripheral vision) on the right in both eyes which relates to the infarcts in Barry’s left occipital lobe. Barry has also been experiencing some visual coordination and balance problems which relate to the infarcts in his cerebellum.

55
Q

What are symptoms of depression?

A

Loss of energy
Suicidal feelings
Physical aches and pains
Self harming
Loss of sex drive or sexual difficulties
Avoiding people, and loss of self-esteem or self-confidence

56
Q

What are some management options to stroke?

A
  • Medications
  • Speech language therapist
  • Physical therapy
  • Home care
57
Q

What medications are used within a few hours of ischemic stroke

A

Most commonly involves using rtPA.

Tissue plasminogen activator (tPA) is a naturally occurring human protease enzyme that activates plasmin (converts plasminogen into plasmin). Plasmin breaks down clots

rtPA (recombinant tPA) is made in a lab using recombinant DNA technology.

rtPA thrombolytic drug to break up and dissolve blood clots, opening blocked blood vessels and restoring blood flow

58
Q

What is the function/effect of plasmin in the body?

A

Plasmin is a fibrinolytic which breaks down the fibrin holding the blood clots together.

59
Q

What is the main goal of rtPA?

A

The main goal of treatment with rtPA is reperfusion of the cerebral vessels.

It is only used to treat an acute ischemic stroke, not a hemorrhagic stroke.

60
Q

What are considerations before undergoing rtPA therapy?

A

Eligible patients should not have any risk factors for significant bleeding events (as rtPA use carries a risk of uncontrollable bleeding and fatality).

For example, they cannot have had recent major surgery, myocardial infarction, or other internal injuries, and they must have normal clotting functions and a sufficient number of platelets. Additionally, the patient should not have significant hypertension.

61
Q

What are some anti-coagulants?

A
  • Aspirin
  • Clopidogrel
  • Dabigatran
  • Dipyridamole
  • Heparin
  • Warfarin
62
Q

What chemical action does Aspirin do?

A

Aspirin: blocks prostaglandin synthetase action

NSAID, reduces platelet aggregation

63
Q

What does Clopidogrel do?

A

Clopidogrel: inhibits receptor P2Y12, a chemoreceptor on platelet cell membranes

64
Q

What does Dabigatran do?

A

Dabigatran: competitive direct inhibitor of thrombin (factor IIa)

65
Q

What does Dipyridamole do?

A

Dipyridamole: inhibits the phosphodiesterase enzyme

66
Q

What does Heparin do?

A

Heparin: inhibits antithrombin III, which ultimately inactivates blood clotting factor Xa and inhibits blood clotting

67
Q

What does Warfarin do?

A

Anticoagulant

Warfarin: inhibits vitamin K-epoxide reductase

68
Q

What medications are barry on?

A
  • Paracetemol
  • Aspirin (NSAID, antithrombotic)
  • Clonidine (vasodilator used to help lower BP)
  • Dipyridamole (prevent postoperative thromboembolic events)
  • Cilazapril (ACE inhibitor, for lowering BP)
  • Diltiazem (calcium channel blocker for lowering BP)
  • Gliclizide (a sulfonylurea which acts by stimulating β cells of the pancreas to release insulin)
  • Citalopram (for low mood/depression)
  • Metacloprimide (enhances movement of the upper GI tract)
  • Omeprazole (proton pump inhibitor for gastroesophageal reflux)
  • Ciprofloxacine (eye drops for corneal ulceration)

A Pathophysiology- BN607 (28 decks)

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