Clinical characteristics of the study participants
The mean fasting blood sugar was 6.6 (SD 3.9) for cases and 5.3 (SD 0.7) for controls. This was statistically significant with a p value of 0.015. Waist to hip ratio was also statistically significant with a p value of 0.007. Cases with an elevated wait to hip ratio were 14 (27.5%) and controls were 3 (5.9%). Table Table2 2 shows the baseline clinical characteristics of the study participants.
| | ||
---|---|---|---|
Systolic blood pressure | 134.3 (31.9) | 129.0 (22.3) | 0.339 |
Diastolic blood pressure | 85.0 (22.4) | 80.5 (18.7) | 0.274 |
Fasting blood sugar | 6.6 (3.9) | 5.3 (0.7) | |
Yes | 21 (41.2) | 13 (25.5) | 0.093 |
No | 30 (58.8) | 38 (74.5) | |
High | 6 (12.0) | 1 (2.0) | 0.060 |
Normal | 44 (88.0) | 50 (98.0) | |
Yes | 14 (27.5) | 8 (15.7) | 0.149 |
No | 37 (72.6) | 43 (84.3) | |
Yes | 16 (31.4) | 18 (35.3) | 0.674 |
No | 35 (68.6) | 33 (64.7) | |
Yes | 2 (4.8) | 0 (0.0) | 0.495 |
No | 49 (96.1) | 51 (100.0) | |
Yes | 4 (7.8) | 8 (15.7) | 0.357 |
No | 47 (92.2) | 43 (84.3) | |
Yes | 2 (3.9) | 0 (0.0) | 0.495 |
No | 49 (96.1) | 51 (100.0) | |
High | 14 (27.5) | 3 (5.9) | |
Normal | 37 (72.6) | 48 (94.1) |
Laboratory characteristics of the study participants
HIV serology and Hb electrophoresis were statistically significant with a p value of 0.076 and 0.023 respectively. 18 patients (35.3%) were reactive for HIV among cases and controls 10 (19.6%). 12 patients (23.5%) had abnormal Hb electrophoresis among cases controls 3 (5.9%). Table Table3 3 shows the laboratory characteristics of the study participants.
| | ||
---|---|---|---|
Normal | 40 (78.4) | 44 (86.3) | 0.299 |
Low/high | 11 (21.6) | 7 (13.7) | |
Normal | 42 (82.4) | 43 (84.3) | 0.790 |
Low/high | 9 (17.7) | 8 (15.7) | |
Normal | 44 (86.3) | 48 (94.1) | 0.318 |
Low/high | 7 (13.7) | 3 (5.9) | |
Normal | 37 (72.6) | 38 (74.5) | 0.822 |
Low/high | 14 (27.5) | 13 (25.5) | |
Normal | 29 (56.9) | 30 (58.8) | 0.841 |
Low/high | 22 (43.1) | 21 (41.2) | |
Normal | 37 (72.6) | 40 (78.4) | 0.490 |
Low/high | 14 (27.5) | 11 (21.6) | |
Normal | 38 (74.5) | 40 (78.4) | 0.641 |
Low/high | 13 (25.5) | 11 (21.6) | |
Reactive | 5 (9.8) | 5 (9.8) | > 0.999 |
Non-reactive | 46 (90.2) | 46 (90.2) | |
Non-Reactive | 33 (64.7) | 41 (80.4) | |
Reactive | 18 (35.3) | 10 (19.6) | |
AA | 39 (76.5) | 48 (94.1) | |
SS | 12 (23.5) | 3 (5.9) |
Stroke types by social demographic characteristics of cases.
Among 62 patients, who had brain CT scan done, 11 patients had non stroke pathologies (4 had brain abscesses, 7 patients had ring enhancing lesions suggestive of toxoplasmosis). Among 51 patients with stroke confirmed on CT scan, the frequency of ischemic stroke was 76.5% and hemorrhagic stroke was 23.5%.
Most participants with ischemic or hemorrhagic stroke were in the age group 36–45 years. Females predominated in both ischemic and hemorrhagic stroke. Details of the social demographic characteristics by stroke types are shown in Table Table4 4 .
Social demographic characteristics by stroke types
| | ||
---|---|---|---|
Overall | 39 (76.5) | 12 (23.5) | |
18–25 | 4 (10.3) | 1 (8.3) | > 0.999 |
26–35 | 10 (25.6) | 3 (25.0) | |
36–45 | 25 (64.1) | 8 (66.7) | |
Male | 17 (43.6) | 5 (41.7) | 0.906 |
Female | 22 (56.4) | 7 (58.3) | |
Protestant | 18 (46.2) | 5 (41.7) | 0.222 |
Catholic | 8 (20.5) | 6 (50.0) | |
Moslem | 9 (23.1) | 1 (8.3) | |
Other | 4 (10.3) | 0 (0.0) | |
Married | 23 (59.0) | 9 (75.0) | 0.721 |
Never married (single) | 8 (20.5) | 2 (16.7) | |
Married before | 8 (20.5) | 1 (8.3) | |
Primary | 17 (43.6) | 5 (41.7) | 0.887 |
Secondary | 11 (28.2) | 5 (41.7) | |
Tertiary | 4 (10.3) | 1 (8.3) | |
Never attended school | 7 (18.0) | 1 (8.3) |
Majority of patients with hemorrhagic stroke were hypertensive (91.7%) compared to only 25.6% among patients with ischemic stroke. Details of the clinical and laboratory characteristics of the study participants by stroke subtypes are shown in Table Table5 5 .
Shows the clinical and laboratory characteristics by stroke types
| | ||
---|---|---|---|
Hypertensive (Yes) | 10 (25.6) | 11 (91.7) | > 0.001 |
High | 4(10.5) | 2(16.7) | 0.621 |
Normal | 34(89.5) | 10(83.3) | |
High | 13(33.3) | 1(8.33) | 0.142 |
Normal | 26(66.7) | 11(91.7) | |
1(2.56) | 0(0.00) | > 0.999 | |
8(20.5) | 3(25.0) | 0.706 | |
3(13.0) | 4(57.4) | 0.033 | |
Normal | 29(74.4) | 8(72.6) | 0.715 |
Low/high | 10(25.6) | 4(33.3) | |
Normal | 23(59.0) | 6(50.0) | 0.583 |
Low/high | 16(41.0) | 6(50.0) | |
Normal | 29 (74.7) | 9(75.0) | > 0.999 |
Low/high | 10(25.6) | 3(25.0) | |
Reactive | 16(41.0) | 2(16.7) | 0.174 |
Non-reactive | 23(59.0) | 10(83.3) | |
AA | 30(77.0) | 9(75.0) | > 0.999 |
SS | 9(23.1) | 3(25.0) |
Social demographic characteristics at univariate analysis
Oral contraceptive use showed a significant difference with an unadjusted OR of 0.27 (95% CI 0.08–0.87) case subjects 23.3% and control subjects 56.5%. Belonging to other religion (seventh day advent, Pentecostal) was statistically significant with a p value of 0.009, OR 0.17. These findings are detailed in Table Table6 6 below.
| | | ||
---|---|---|---|---|
Mean (SD) | 36.8 (7.4) | 36.8 (6.9) | ||
18–25 | 5 (9.8) | 4 (7.8) | ||
26–35 | 13 (25.5) | 17 (33.3) | ||
36–45 | 33 (64.7) | 30 (58.8) | ||
Male | 22 (43.1) | 24 (47.1) | ||
Female | 29 (56.9) | 27 (52.9) | ||
Protestant | 23 (45.1) | 14 (27.5) | Reference | |
Catholic | 14 (27.5) | 17 (33.3) | 0.44 (0.16 – 1.20) | 0.110 |
Moslem | 10 (19.6) | 7 (13.7) | 0.71 (0.22 – 2.28) | 0.567 |
Other | 4 (7.8) | 13 (25.5) | 0.17 (0.05 – 0.65) | |
Married | 32 (62.8) | 31 (60.8) | Reference | |
Never married (single) | 10 (19.6) | 12 (23.5) | 0.70 (0.24 – 2.02) | 0.509 |
Married before | 9 (17.7) | 8 (15.7) | 0.88 (0.27 – 2.79) | 0.823 |
Primary | 22 (43.1) | 19 (37.3) | Reference | |
Secondary | 16 (31.4) | 21 (41.2) | 0.58 (0.23 – 1.47) | 0.250 |
Tertiary | 5 (9.8) | 6 (11.8) | 0.62 (0.16 – 2.38) | 0.485 |
Yes | 1 (2.0) | 2 (3.9) | 0.34 (0.03 – 3.95) | 0.390 |
No | 50 (98.0) | 49 (96.1) | Reference | |
Yes | 4 (7.8) | 5 (9.8) | 0.80 (0.19 – 3.30) | 0.755 |
No | 47 (92.2) | 46 (90.2) | Reference | |
Yes | 11 (21.6) | 11 (21.6) | 0.97 (0.38 – 2.48) | 0.946 |
No | 40 (78.4) | 40 (78.4) | Reference | |
Yes | 1 (2.0) | 1 (2.0) | 1.31 (0.08 – 21.07) | 0.849 |
No | 50 (98.0) | 50 (98.0) | Reference | |
Yes | 7 (24.1) | 14 (51.9) | 0.30 (0.09–0.98) | |
No | 22 (75.9) | 13 (48.1) | Reference |
a Obtained accounting for matching by age and sex using a conditional logistic regression
b No comparison made because matching was done using these variables (age and sex)
c Accounting for matching was done only for age because contraceptive use applies only to female gender
There was a significant difference in waist to hip ratio between cases (27.5%) and controls (5.9%), with unadjusted OR 6.85 (CI 1.70–27.62). HIV serology with an unadjusted OR of 2.64 (95% CI 1.03–6.82). Hb electrophoresis with an unadjusted OR of 4.31 (95% CI- 1.15–16.17). Fasting blood sugar with an unadjusted OR of 1.64 (95% CI 1.02–2.62). Details of the above findings are shown in Table Table7 7 below.
Clinical characteristics of study participants at univariate analysis
| | |||
---|---|---|---|---|
| ||||
Systolic blood pressure | 134.3 (31.9) | 129.0 (22.3) | 1.01 (0.99 – 1.02) | 0.397 |
Diastolic blood pressure | 85.0 (22.4) | 80.5 (18.7) | 1.01 (0.99 – 1.03) | 0.319 |
Fasting blood sugar | 6.6 (3.9) | 5.3 (0.7) | 1.64 (1.02 – 2.62) | |
| ||||
Yes | 21 (41.2) | 13 (25.5) | 1.78 (0.77 – 4.12) | 0.175 |
No | 30 (58.8) | 38 (74.5) | Reference | |
High | 6 (12.0) | 1 (2.0) | 5.61 (0.12 – 48.65) | 0.118 |
Normal | 44 (88.0) | 50 (98.0) | Reference | |
Yes | 14 (27.5) | 8 (15.7) | 1.77 (0.66 – 4.75) | 0.257 |
No | 37 (72.6) | 43 (84.3) | Reference | |
Yes | 16 (31.4) | 18 (35.3) | 0.77 (0.34 – 1.75) | 0.537 |
No | 35 (68.6) | 33 (64.7) | Reference | |
Yes | 2 (4.8) | 0 (0.0) | 3.12 (0.24 – 167.1) | 0.308 |
No | 49 (96.1) | 51 (100.0) | Reference | |
Yes | 4 (7.8) | 8 (15.7) | 0.39 (0.10 – 1.44) | 0.156 |
No | 47 (92.2) | 43 (84.3) | Reference | |
Yes | 2 (3.9) | 0 (0.0) | 3.12 (0.24 – 167.1) | 0.308 |
No | 49 (96.1) | 51 (100.0) | Reference | |
High | 14 (27.5) | 3 (5.9) | 6.85 (1.70 – 27.62) | |
Normal | 40 (78.4) | 44 (86.3) | Reference | |
Low/high | 11 (21.6) | 7 (13.7) | 1.63 (0.56 – 4.73) | 0.369 |
Normal | 42 (82.4) | 43 (84.3) | Reference | |
Low/high | 9 (17.7) | 8 (15.7) | 1.17 (0.40 – 3.37) | 0.777 |
Normal | 44 (86.3) | 48 (94.1) | Reference | |
Low/high | 7 (13.7) | 3 (5.9) | 2.58 (0.63 – 10.59) | 0.188 |
Normal | 37 (72.6) | 38 (74.5) | Reference | |
Low/high | 14 (27.5) | 13 (25.5) | 1.07 (0.43 – 2.63) | 0.891 |
Normal | 29 (56.9) | 30 (58.8) | Reference | |
Low/high | 22 (43.1) | 21 (41.2) | 0.97 (0.43 – 2.16) | 0.933 |
Normal | 37 (72.6) | 40 (78.4) | Reference | |
Low/high | 14 (27.5) | 11 (21.6) | 1.41 (0.58 – 3.46) | 0.450 |
Normal | 38 (74.5) | 40 (78.4) | Reference | |
Low/high | 13 (25.5) | 11 (21.6) | 1.32 (0.53 – 3.29) | 0.556 |
Reactive | 5 (9.8) | 5 (9.8) | Reference | |
Non-reactive | 46 (90.2) | 46 (90.2) | 1.04 (0.28 – 3.93) | 0.953 |
Non-Reactive | 33 (64.7) | 41 (80.4) | Reference | |
Reactive | 18 (35.3) | 10 (19.6) | 2.64 (1.03–6.82) | |
AA | 39 (76.5) | 48 (94.1) | Reference | |
SS | 12 (23.5) | 3 (5.9) | 4.31 (1.15 – 16.17) |
b Obtained by adding a 1 on each cell count (due to zero cell count)
c High (male: > 0.95, female > 0.85); Normal (male: < 0.95, female < 0.85)
Risk factors for stroke at multivariate analysis
At multivariate analysis, HIV serology (OR 3.72, 95% CI 1.16–10.96), waist to hip ratio (OR 11.26 95% CI 1.98–68.24) and sickle cell disease OR 4.78 95% CI 1.11–19.70) were independent risk factors for stroke in young adults. Table Table8 8 shows risk factors at multivariate analysis. None of the patients with HIV met the definition of AIDS as defined by the occurrence of any of the more than 20 life-threatening cancers or “opportunistic infections”, by WHO.
| ||||
---|---|---|---|---|
Non−reactive | 33 (64.7) | 41 (80.4) | Reference | 0.025 |
Reactive | 18 (35.3) | 10 (19.6) | 3.72 (1.18–11.75) | |
Normal | 37 (72.6) | 48 (94.1) | Reference | |
High | 14 (27.5) | 3 (5.9) | 11.26 (1.64–77.24) | 0.014 |
AA | 39 (76.5) | 48 (94.1) | Reference | 0.034 |
SS | 12 (23.5) | 3 (5.9) | 4.78 (1.12–20.37) | |
Yes | 4 (7.8) | 8 (15.7) | Reference | 0.047 |
No | 47 (92.2) | 43 (84.3) | 8.48 (1.03–70.11) | |
Protestant | 23 (45.1) | 14 (27.5) | Reference | |
Catholic | 14 (27.5) | 17 (33.3) | 0.44 (0.13–1.51) | 0.194 |
Moslem | 10 (19.6) | 7 (13.7) | 0.53 (0.13–2.23) | 0.390 |
Other | 4 (7.8) | 13 (25.5) | 0.09 (0.01–0.56) | 0.010 |
Normal | 44(88.0) | 50(98.0) | Reference | |
High | 6(12.0) | 1(2.0) | 8.06(0.43–152.78) | 0.164 |
a High (male: > 0.95, female > 0.85); Normal (male: < 0.95, female < 0.85)
b Obtained accounting for matching by age and sex using a conditional logistic regression
Variables with p value < 0.2 included in multivariant analysis include fasting blood sugar, hypertension, family of diabetes mellitus, waist to hip ratio, leucocyte count, HIV serology, sickle cell disease and oral contraceptive use
This case–control study showed that the frequency of ischemic stroke was higher than that of hemorrhagic stroke in young Ugandan population. We showed that positive HIV serology, elevated waist to hip ratio and sickle cell disease were independent risk factors for stroke in this population.
This is consistent with several studies that have been done and found ischemic stroke to be more prevalent than hemorrhagic stroke. Studies done in Africa, in Libya reported 77% ischemic stroke and 23% hemorrhagic stroke (these included both intracerebral and subarachnoid hemorrhagic stroke) [ 14 ], in Morocco, 87.3% ischemic stroke and 12.7% hemorrhagic (study did not specify on the subtypes of hemorrhagic stroke) [ 6 ]. In a study from Bosnia and Herzegovina, Subarachnoid hemorrhage was more frequent in young adults compared with older patients (> 45 years of age) (22% vs. 3.5%), intracerebral hemorrhage (ICH) was similar in both groups (16.9% vs. 15.8%), but ischemic stroke (IS) was predominant stroke type in the older group (61% vs. 74%) [ 15 ]. On the other hand, studies focusing on all young stroke patients and including also subarachnoid hemorrhages have found much higher proportion of hemorrhagic strokes in younger vs. older individuals. Population-based studies have reported as low as 57% prevalence for ischemic stroke in those aged > 45, as reported by a recent narrative review [ 16 ]. This difference in occurrence of stroke subtypes could be due to the low prevalence of hypertension in this population in our setting given that hypertension has been reported to be the commonest risk factor for hemorrhagic stroke.
Most previous studies of HIV and stroke have been retrospective, but the prospective studies in Africa and East Africa have reported the importance of HIV as a risk factor for stroke [ 17 ]. A recently published study done in Malawi, with defined cases and population controls and 99% ascertainment of HIV status, reported HIV infection as an independent risk factor for stroke. This study further found that patients who had started standard HIV treatment in the previous six months had a higher risk of stroke (OR 15.6 95% CI 4.21–46.6). This was probably due to an immune reconstitution inflammatory syndrome (IRIS) like process [ 18 ]. A variety of mechanisms have been implicated in the association of HIV and stroke, these include HIV associated vasculopathy, vasculitis which causes abnormality of the intracranial or extracranial cerebral blood vessels and neoplastic involvement. Indirectly through cardioembolic, coagulopathy in association with protein C and protein S deficiency. Some infections are well established causes of stroke, such as Mycobacterium tuberculosi s , syphilis, and varicella zoster virus through increased susceptibility to acquisition or reactivation of these infections [ 19 , 20 ]. Combined antiretroviral therapy (cART) might unmask occult opportunistic infections that subsequently cause a stroke. This possibility should be considered in all patients who have had an acute stroke or have worsening of stroke symptoms after initiation of cART [ 21 ].
An elevated waist to hip ratio (WHR) was associated with 12 times increased risk of stroke among young adults in Mulago hospital compared to individuals with a normal waist to hip ratio. Abdominal obesity (measured as waist–hip ratio) is associated with an increased risk of myocardial infarction, stroke, and premature death [ 22 ]. This agrees with a few studies that have assessed the association of stroke with waist to hip ratio. Aaron et al. 1990, assessed the relation between body fat distribution, and the 2-year incidences of hypertension and stroke in a cohort of 41,837 women aged 55–69 years. Women who developed stroke were 2.1 (95% CI 1.5–2.9) times more likely to have an elevated ratio than those who did not [ 23 ]. Md Habib et al. 2011 assessed high waist to hip ratio as a risk factor for ischemic stroke for overall stroke and he found 64% of the ischemic stroke patient had abnormal WHR in Bangladesh [ 24 ]. Abdominal obesity measured with WHR was an independent risk factor for cryptogenic ischemic stroke (CIS) in young adults after rigorous adjustment for concomitant risk factors in the Revealing the Etiology, Triggers, and Outcome (SECRETO; {"type":"clinical-trial","attrs":{"text":"NCT01934725","term_id":"NCT01934725"}} NCT01934725 ) study, a prospective case–control study that included patients aged 18–49 years with a first ever CIS at 19 European university centers [ 25 ].
Sickle cell disease was also associated with increased risk of stroke among young adults in Mulago hospital. This agrees with several studies that have associated sickle cell disease with stroke. Ohene et al. 1998 assessed cerebrovascular accidents (CVA) in sickle cell disease, found the highest rates of prevalence of 4.01% and incidence of 0.61 per 100 patient-years. The incidence of hemorrhagic stroke was highest among patients aged 20 to 29 years [ 26 ].
In our study, the unadjusted OR for oral contraceptive use was 0.26 95% CI 0.08–0.87 with a p value of 0.028. This observation at the unadjusted level is significant but could be due to another variable which is a confounder to OC use such as higher socioeconomic status and better control of other possible risk factors.
In our study, we found no association between hypertension and stroke in young adults though it’s an independent risk factor for stroke in the older population. This finding is different from the multinational interstroke study which attributed most strokes among young adults in low- and middle-income countries to hypertension. In that study, only one fifth of the patients were from wealthier African countries where hypertension, diabetes and hypercholesterolemia are likely to occur with higher prevalence than in Mulago hospital [ 27 ]. Other studies have also reported the role of hypertension as a risk factor for stroke in young adults, low physical activity and hypertension were the most important risk factors, accounting for 59.7% and 27.1% of all strokes, respectively among a German nationwide case–control study based on patients enrolled in the SIFAP1 study (Stroke in Young Fabry Patients) 2007 to 2010 and controls from the population-based GEDA study (German Health Update) 2009 to 2010 [ 28 ]. A study that used population-based controls for hospitalized young patients with ischemic stroke demonstrated that independent risk factors for stroke were atrial fibrillation (OR 10.43; cardiovascular disease (OR, 8.01; type 1 diabetes mellitus (OR, 6.72; type 2 diabetes mellitus (OR, 2.31, low high‐density lipoprotein cholesterol (OR, 1.81; current smoking status (OR, 1.81; hypertension (OR, 1.43, and a family history of stroke (OR, 1.37) [ 29 ].
This finding could be explained by the high prevalence of hypertension in the general peri urban Ugandan population among young adults as reported by Kayima et al. 2015. He found a prevalence of 15% (95% CI 14.2 – 19.6%) % for young adults aged 18–44 years [ 30 ].
The study was conducted at Mulago hospital which is a national referral hospital in Uganda situated in central Uganda. Mulago hospital received patients both referred patients from all over Uganda and those from its catchment area. This is generally representative of the whole Ugandan population.
Uganda has a young population and with an HIV prevalence comparable to most countries in Sub-Saharan Africa, so the findings of this study are generalizable to other Sub-Saharan African populations.
Ischemic stroke is more prevalent than hemorrhagic stroke among young adults in Mulago hospital. Independent risk factors for stroke among young adults in Mulago hospital were HIV infection, elevated waist to hip ratio and sickle cell disease. Oral contraceptive use was found to be protective of stroke among young adults in Mulago hospital. There was no significant association between stroke among young adults and hypertension, diabetes, hyperlipidemia, smoking, alcohol use and illicit use.
We acknowledge the patients of Mulago hospital who gave us consent to obtain this information.
PN– conception, design of work, acquisition, analysis, interpretation of data, drafted and substantively revised the manuscript, JN– analysis, interpretation of data, drafted and substantively revised the manuscript, MK – analysis, interpretation of data, drafted and substantively revised the manuscript, EK– design of work, acquisition, analysis, interpretation of data, drafted and substantively revised the manuscript. All authors read and approved the final manuscript.
This study was funded with funds from the MEPI-Neurology program under Makerere University. The funding project had no role in the design of the study and collection, analysis, and interpretation of data and no role in writing the manuscript.
Declarations.
Written informed consent/ assent was obtained from all participants or their parent/guardian or legal authorized representative to participate in the study. Ethical approval was obtained from Makerere University, school of medicine research and ethics committee (SOMREC) (reference number #REC REF 2015–105). All methods and procedures were carried out in accordance with relevant guidelines and regulations.
Not applicable.
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Course case studies, external link, this link leads outside of the netce site to:.
While we have selected sites that we believe offer good, reliable information, we are not responsible for the content provided. Furthermore, these links do not constitute an endorsement of these organizations or their programs by NetCE, and none should be inferred.
Course #90284 - $60 -
Your certificate(s) of completion have been emailed to
Patient M is an active woman, 70 years of age, who lost consciousness and collapsed at home. Her daughter, who was visiting her at the time, did not witness the collapse but found her mother on the floor, awake, confused, and slightly short of breath. The daughter estimated that she called EMS within 5 minutes after the collapse, and EMS responded within 15 minutes. EMS evaluated Patient M, drew blood for a glucose level, and determined that she may have had a stroke. They notified the nearest designated comprehensive stroke center that they would be arriving with the patient in approximately 20 minutes. Patient M's daughter accompanied her.
The triage and transportation of an individual with suspected stroke should be similar to that for an individual with serious trauma, and treatment is recommended within 3 hours after the onset of stroke. Because of the limited time available for assessment and diagnosis before optimal treatment, the EMS dispatcher should notify EMS personnel immediately and coordinate transport of the individual to the closest emergency facility, preferably one that is a designated primary (or comprehensive) stroke care center.
On presentation in the emergency department, Patient M is immediately triaged. Because Patient M is still somewhat confused, her daughter is asked to provide information on the patient's history. The daughter reports that her mother had had an episode of sudden-onset numbness and tingling in the right limb, with slight confusion and slurred speech, 3 days previously. The episode lasted only 5 minutes, and Patient M had not called her primary care physician. Additional information provided by the daughter indicates that Patient M has been treated for hypertension for 10 years but notes that she is often not compliant with her antihypertensive medicine, a diuretic. The patient has never smoked, drinks occasionally, and is of normal weight.
Patient M has two significant risk factors for stroke; one is a long history of hypertension. More than two-thirds of individuals older than 65 years of age are hypertensive, and it is important for individuals with hypertension to have regular blood pressure screening and to maintain a blood pressure of less than 140/90 mm Hg. Antihypertension therapy has been found to reduce the incidence of stroke by 30% to 40%. Patient M's noncompliance with her antihypertension medicine likely includes her among the 65% of known hypertensive individuals in whom blood pressure is not controlled.
Patient M's previous episode of numbness, confusion, and slurred speech appears to be evidence of a TIA, another substantial risk factor for stroke. Research has shown that approximately 5% of patients will have an ischemic stroke within 7 days after a TIA. In addition, the risk of stroke within 7 days is doubled for patients with TIAs who did not seek treatment. As is the case for many individuals who have a TIA, Patient M did not seek medical attention because the clinical symptoms resolved quickly. However, research findings indicate that urgent treatment should be provided for TIAs, as early treatment for TIA and minor stroke has been shown to reduce the risk of early recurrent stroke by 80%.
On physical examination, Patient M's blood pressure is 150/95 mm Hg. She has pain in her left arm and a slight headache. There is a focal carotid bruit on the right. She is assessed with use of the NIHSS and found to have 1/5 weakness in the left upper and lower extremities and left visual/spatial neglect. The results of laboratory tests, including a complete blood count, prothrombin time, serum electrolyte levels, cardiac biomarkers, and renal function studies, are all within normal limits. CT of the head obtained about 45 minutes into her ED evaluation (1.5 to 2 hours since last well) indicates an occlusion in a branch of the right internal carotid artery with 50% narrowing due to atherosclerosis. An area of ischemia/infarction is visible in the right anterior cerebral hemisphere. There is no evidence of subarachnoid hemorrhage. Approximately 2.5 to 3 hours after Patient M collapsed at home, she is treated with IV rt-PA at a dose of 0.9 mg/kg. Twenty-four hours later, aspirin antiplatelet therapy is started at an initial dose of 325 mg, and a maintenance dose of 75 mg per day.
Many of the patient's symptoms, including her loss of consciousness, shortness of breath, pain, and headache, are nontraditional symptoms of stroke. Studies have demonstrated that nontraditional symptoms are more prevalent among women, often leading to a delay in the evaluation for stroke. EMS personnel and clinicians should be aware of the potential for nontraditional symptoms in women and carry out a diagnostic evaluation addressing a suspicion of stroke.
Patient M is eligible for thrombolytic therapy with rt-PA according to evidence-based guidelines developed by the AHA/ASA: her blood pressure is lower than 185/110 mm Hg, the onset of symptoms is less than 3 hours prior to the start of treatment, and the laboratory values are within normal limits. Antiplatelet therapy with aspirin 325 mg daily (versus anticoagulant therapy with warfarin) is recommended for treatment of patients with stroke or TIA due to intracranial atherosclerosis with 50% to 99% occlusion. Antiplatelet therapy is not recommended as an adjunctive therapy within 24 hours of thrombolytic therapy.
When Patient M's condition is stabilized, her primary care physician and consultant neurologist provide a referral for stroke rehabilitation, and a multidisciplinary rehabilitation team is formed to assess her rehabilitative needs, recommend the proper rehabilitation setting, and develop a treatment strategy tailored to her specific needs that includes daily antiplatelet therapy. Patient M is again assessed with the NIHSS, and the score is 12. The patient's cognitive and communication skills are intact on evaluation with the FIM, with the exception of the previously documented left visual/spatial neglect. The assessment also includes evaluation of the patient's risk for complications. Because of her spatial neglect, she is screened with the Berg Balance Scale and the Stops Walking When Talking test. The score on the Berg Balance Scale is 43, and Patient M does stop walking to engage in conversation. Psychosocial assessment includes screening with the Center for Epidemiologic Studies Depression (CES-D) Scale, as well as review of the medical history and conversations with the patient and her children; no signs of depression are present.
Patient M's score of 12 on the NIHSS falls within the range (6 to 15) that indicates she is likely to benefit from rehabilitation. Evaluating a stroke survivor's risk of complications is an important component of the overall assessment, and among the most common complications are falls, deep vein thrombosis, pressure ulcers, swallowing dysfunction, bladder and bowel dysfunction, and depressive symptoms. In assessing the risk of complications, the Berg Balance Scale appears to be the most appropriate screen for patients who are likely to fall, and a score of less than 45 is associated with a likelihood of falling. The risk of a fall is also increased when a patient stops walking to talk, as Patient M did, during the Stops Talking When Walking test.
Screening for signs of depression is also essential, as depression affects approximately 33% of stroke survivors. Signs of depression are subtle and may be vague. Several screening tools are available, but there is no universally accepted tool for use in the post-stroke setting. The CES-D was chosen in this case because it is easy to administer, is useful in older individuals, and has been found to be effective for screening in the stroke population, except for individuals who have aphasia. The diagnosis of depression in stroke survivors should be based on sources in addition to a formal screening tool, such as a medical evaluation, patient self-report, observation of patient behavior, patient history, and staff reports of changes in behavior and motivation.
The rehabilitation team discusses the results of the assessment with Patient M's daughter and son, both of whom live about 45 minutes away from the patient. Together, the team and the family members explore options to determine the best approach to rehabilitation. A decision is made to transfer Patient M to an inpatient stroke unit, and a rehabilitation program is developed. The nurse on the team discusses the program with Patient M and her children and explains the course of rehabilitation and the expectations. Rehabilitation will focus on an exercise program consisting of aerobic exercise, strength training, stretching, and coordination and balance activities.
Early initiation of rehabilitation is a particularly strong predictor of improved outcome, and rehabilitation in a stroke unit has been associated with improved quality of life, survival, and functional status at 5 years compared with a general healthcare facility. No studies have demonstrated the superiority of one rehabilitation setting over another, and the inpatient setting was chosen primarily to ensure consistent care, given how far away Patient M's children live, and the limited support she otherwise has for healthcare needs. Decisions about the setting and program for rehabilitation should be shared with family members, and family and other caregivers should be provided with educational resources about the rehabilitation process.
The exercise program developed for Patient M is designed to help her regain the ability to independently carry out activities of daily living safely and to regain a functional level of ambulation. The benefits of an exercise program include increasing fitness, strength, and flexibility; improving function; preventing injuries and falls; and reducing the risk of recurrent stroke.
Patient M gradually resumes the ability to function independently, and after more than 2 weeks in the stroke rehabilitation unit, the score on the NIHSS has improved to 5. Before she is discharged to her home, the rehabilitation team provides instructions for exercises to continue at home and recommends moderate physical activity as a secondary prevention measure. The team also educates Patient M about the importance of maintaining a normal blood pressure through use of her antihypertension medication and lifestyle modifications. At a follow-up visit with her primary care clinician at 3 months, Patient M's blood pressure is 135/80 mm Hg, and she reports that she has been compliant with her antihypertension medicine and antiplatelet therapy and is functioning well at home.
Copyright © 2024 NetCE · Contact Us
On this page, social work report, social work report: background, social work report: social history, social work report: current function, social work report: the current risks, social work report: attempts to trial least restrictive options, social work report: recommendation, medical report, medical report: background information, medical report: financial and legal affairs, medical report: general living circumstances.
This is a fictitious case that has been designed for educative purposes.
Mrs Beryl Brown URN102030 20 Hume Road, Melbourne, 3000 DOB: 01/11/33
Date of application: 20 August 2019
Mrs Beryl Brown (01/11/33) is an 85 year old woman who was admitted to the Hume Hospital by ambulance after being found by her youngest daughter lying in front of her toilet. Her daughter estimates that she may have been on the ground overnight. On admission, Mrs Brown was diagnosed with a right sided stroke, which has left her with moderate weakness in her left arm and leg. A diagnosis of vascular dementia was also made, which is overlaid on a pre-existing diagnosis of Alzheimer’s disease (2016). Please refer to the attached medical report for further details.
I understand that Mrs Brown has been residing in her own home, a two-story terrace house in Melbourne, for almost 60 years. She has lived alone since her husband died two years ago following a cardiac arrest. She has two daughters. The youngest daughter Jean has lived with her for the past year, after she lost her job. The eldest daughter Catherine lives on the Gold Coast with her family. Mrs Brown is a retired school teacher and she and both daughters describe her as a very private woman who has never enjoyed having visitors in her home. Mrs Brown took much encouragement to accept cleaning and shopping assistance once a week after her most recent admission; however, she does not agree to increase service provision. Jean has Enduring Power of Attorney (EPOA) paperwork that indicates that Mrs Brown appointed her under an EPOA two years ago. She does not appear to have appointed a medical treatment decision maker or any other decision-supporter.
I also understand from conversations with her daughters that Jean and Mrs Brown have always been very close and that there is a history of long-standing conflict between Catherine and Jean. This was exacerbated by the death of their father. Both daughters state they understand the impact of the stroke on their mother’s physical and cognitive functioning, but they do not agree on a discharge destination. Mrs Brown lacks insight into her care needs and says she will be fine once she gets back into her own home. Repeated attempts to discuss options with all parties in the same room have not resulted in a decision that is agreeable to all parties.
Mrs Brown has a history of Alzheimer’s disease; type II diabetes – insulin dependent; hypertension; high cholesterol and osteoarthritis. She has had two recent admissions to hospital for a urinary tract infection and a fall in the context of low blood sugars. She is currently requiring one to two people to assist her into and out of bed and one person with managing tasks associated with post-toilet hygiene. She can walk slowly for short distances with a four-wheel frame with one person to supervise. She benefits from prompting to use her frame; she needs someone to cut her food and to set her up to eat and drink regularly and to manage her medication routine. She requires one person to assist her to manage her insulin twice daily.
The team believe that Mrs Brown’s capacity for functional improvement has plateaued in the last ten days. They recommend that it is in her best interests to be discharged to a residential care setting due to her need for one to two people to provide assistance with the core tasks associated with daily living. Mrs Brown is adamant that she wants to return home to live with Jean who she states can look after her. Jean, who has a history of chronic back pain, has required several admissions to hospital over the past five years, and states she wants to be able to care for her mother at home. Jean states she is reluctant to agree to extra services as her mother would not want this. Her sister Catherine is concerned that Jean has not been coping and states that given this is the third admission to hospital in a period of few months, believes it is now time for her mother to enter residential care. Catherine states that she is very opposed to her mother being discharged home.
Mrs Brown is at high risk of experiencing falls. She has reduced awareness of the left side of her body and her ability to plan and process information has been affected by her stroke. She is now requiring one to two people to assist with all her tasks of daily living and she lacks insight into these deficits. Mrs Brown is also at risk of further significant functional decline which may exacerbate Jean’s back pain. Jean has stated she is very worried about where she will live if her mother is to enter residential care.
We have convened two family meetings with Mrs Brown, both her daughters and several members of the multi-disciplinary team. The outcome of the first meeting saw all parties agree for the ward to provide personalised carer training to Jean with the aim of trialling a discharge home. During this training Jean reported significant pain when transferring her mother from the bed and stated she would prefer to leave her mother in bed until she was well enough to get out with less support.
The team provided education to both Jean and Catherine about the progressive impact of their mother’s multiple conditions on her functioning. The occupational therapist completed a home visit and recommended that the downstairs shower be modified so that a commode can be placed in it safely and the existing dining room be converted into a bedroom for Mrs Brown. Mrs Brown stated she would not pay for these modifications and Jean stated she did not wish to go against her mother’s wishes. The team encouraged Mrs Brown to consider developing a back-up plan and explore residential care options close to her home so that Jean could visit often if the discharge home failed. Mrs Brown and Jean refused to consent to proceed with an Aged Care Assessment that would enable Catherine to waitlist her mother’s name at suitable aged care facilities. We proceeded with organising a trial overnight visit. Unfortunately, this visit was not successful as Jean and Catherine, who remained in Melbourne to provide assistance, found it very difficult to provide care without the use of an accessible bathroom. Mrs Brown remains adamant that she will remain at home. The team is continuing to work with the family to maximise Mrs Brown’s independence, but they believe that it is unlikely this will improve. I have spent time with Jean to explore her adjustment to the situation, and provided her with information on community support services and residential care services. I have provided her with information on the Transition Care Program which can assist families to work through all the logistics. I have provided her with more information on where she could access further counselling to explore her concerns. I have sought advice on the process and legislative requirements from the Office of the Public Advocate’s Advice Service. I discussed this process with the treating team and we decided that it was time to lodge an application for guardianship to VCAT.
The treating team believe they have exhausted all least restrictive alternatives and that a guardianship order is required to make a decision on Mrs Brown’s discharge destination and access to services. The team recommend that the Public Advocate be appointed as Mrs Brown’s guardian of last resort. We believe that this is the most suitable arrangement as her daughters are not in agreement about what is in their mother’s best interests. We also believe that there is a potential conflict of interest as Jean has expressed significant concern that her mother’s relocation to residential care will have an impact on her own living arrangements.
Mrs Brown’s medical history includes Alzheimer’s disease; type II diabetes; hypertension; high cholesterol and osteoarthritis. She was admitted to Hume Hospital on 3 March 2019 following a stroke that resulted in moderate left arm and leg weakness. This admission was the third hospital admission in the past year. Other admissions have been for a urinary tract infection, and a fall in the context hypoglycaemia (low blood sugars), both of which were complicated by episodes of delirium.
She was transferred to the subacute site under my care, a week post her admission, for slow-stream rehabilitation, cognitive assessment and discharge planning.
Mrs Brown was diagnosed with Alzheimer’s disease by Dr Joanne Winters, Geriatrician, in April 2016. At that time, Mrs Brown scored 21/30 on the Standardised Mini-Mental State Examination (SMMSE). During this admission, Mrs Brown scored 15/30. I have undertaken cognitive assessment and agree with the diagnosis; further cognitive decline has occurred in the context of the recent stroke. There are global cognitive deficits, but primarily affecting memory, attention and executive function (planning, problem solving, mental flexibility and abstract reasoning). The most recent CT-Brain scan shows generalised atrophy along with evidence of the new stroke affecting the right frontal lobe. My assessments suggest moderate to severe mixed Alzheimer’s and vascular dementia.
While able to recall some key aspects of her financial affairs, including the general monetary value of her pension and regular expenses, Mrs Brown was unable to account for recent expenditure (for repairs to her home) or provide an estimate of its value, and had difficulty describing her investments. In addition, I consider that she would be unable to make complex financial decisions due to her level of cognitive impairment. Accordingly, I am of the view that Mrs Brown now lacks capacity to make financial decisions.
Mrs Brown states that she previously made an Enduring Power of Attorney (EPOA) but could no longer recall aspects of the EPOA, such as when it would commence and the nature of the attorney’s powers. Moreover, she confused the EPOA with her will. Her understanding of these matters did not improve with education, and therefore I consider that she no longer has capacity to execute or revoke an EPOA.
Mrs Brown acknowledges that she needs some assistance but lacks insight into the type of assistance that she requires, apart from home help for cleaning and shopping. She does not appreciate her risk of falling. She is unable to get in and out of bed without at least one person assisting her. She frequently forgets to use her gait aid when mobilising and is not able to describe how she would seek help in the event of falling. She is not able to identify or describe how she would manage her blood sugar levels, and this has not improved with education. Accordingly, I consider that she lacks capacity to make decisions about accommodation arrangements and services.
Mrs Brown does not agree with the treating team’s recommendation to move into residential care and maintains her preference to return home. This is in spite of a failed overnight trial at home with both her daughters assisting her. Unfortunately, she was unable to get out of bed to get to the toilet and required two people to assist her to do so in the morning. In light of these matters, and in the context of family disagreement regarding the matter, the team recommends that the Office of the Public Advocate be appointed as a guardian of last resort.
Reviewed 22 July 2022
This presents an analysis of a case of Ischemic stroke in terms of possible etiology, pathophysiology, drug analysis and nursing care
View file(s).
Item link - use this link for citations and online mentions..
Clinical Focus: Adult Medical/Surgical
Type information.
Type | | |
Evidence Level | ; ; |
2017-12-07 |
Name |
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.
All permission requests should be directed accordingly and not to the Sigma Repository.
All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
A 66-year-old man was admitted to hospital with a right frontal cerebral infarct producing left-sided weakness and a deterioration in his speech pattern. The cerebral infarct was confirmed with CT imaging. The only evidence of respiratory symptoms on admission was a 2 L oxygen requirement, maintaining oxygen saturations between 88% and 92%. In a matter of hours this patient developed a greater oxygen requirement, alongside reduced levels of consciousness. A positive COVID-19 throat swab, in addition to bilateral pneumonia on chest X-ray and lymphopaenia in his blood tests, confirmed a diagnosis of COVID-19 pneumonia. A proactive decision was made involving the patients’ family, ward and intensive care healthcare staff, to not escalate care above a ward-based ceiling of care. The patient died 5 days following admission under the palliative care provided by the medical team.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .
https://doi.org/10.1136/bcr-2020-235920
Request permissions.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is a new strain of coronavirus that is thought to have originated in December 2019 in Wuhan, China. In a matter of months, it has erupted from non-existence to perhaps the greatest challenge to healthcare in modern times, grinding most societies globally to a sudden halt. Consequently, the study and research into SARS-CoV-2 is invaluable. Although coronaviruses are common, SARS-CoV-2 appears to be considerably more contagious. The WHO figures into the 2003 SARS-CoV-1 outbreak, from November 2002 to July 2003, indicate a total of 8439 confirmed cases globally. 1 In comparison, during a period of 4 months from December 2019 to July 2020, the number of global cases of COVID-19 reached 10 357 662, increasing exponentially, illustrating how much more contagious SARS-CoV-2 has been. 2
Previous literature has indicated infections, and influenza-like illness have been associated with an overall increase in the odds of stroke development. 3 There appears to be a growing correlation between COVID-19 positive patients presenting to hospital with ischaemic stroke; however, studies investigating this are in progress, with new data emerging daily. This patient report comments on and further characterises the link between COVID-19 pneumonia and the development of ischaemic stroke. At the time of this patients’ admission, there were 95 positive cases from 604 COVID-19 tests conducted in the local community, with a predicted population of 108 000. 4 Only 4 days later, when this patient died, the figure increased to 172 positive cases (81% increase), illustrating the rapid escalation towards the peak of the pandemic, and widespread transmission within the local community ( figure 1 ). As more cases of ischaemic stroke in COVID-19 pneumonia patients arise, the recognition and understanding of its presentation and aetiology can be deciphered. Considering the virulence of SARS-CoV-2 it is crucial as a global healthcare community, we develop this understanding, in order to intervene and reduce significant morbidity and mortality in stroke patients.
A graph showing the number of patients with COVID-19 in the hospital and in the community over time.
A 66-year-old man presented to the hospital with signs of left-sided weakness. The patient had a background of chronic obstructive pulmonary disease (COPD), atrial fibrillation and had one previous ischaemic stroke, producing left-sided haemiparesis, which had completely resolved. He was a non-smoker and lived in a house. The patient was found slumped over on the sofa at home on 1 April 2020, by a relative at approximately 01:00, having been seen to have no acute medical illness at 22:00. The patients’ relative initially described disorientation and agitation with weakness noted in the left upper limb and dysarthria. At the time of presentation, neither the patient nor his relative identified any history of fever, cough, shortness of breath, loss of taste, smell or any other symptoms; however, the patient did have a prior admission 9 days earlier with shortness of breath.
The vague nature of symptoms, entwined with considerable concern over approaching the hospital, due to the risk of contracting COVID-19, created a delay in the patients’ attendance to the accident and emergency department. His primary survey conducted at 09:20 on 1 April 2020 demonstrated a patent airway, with spontaneous breathing and good perfusion. His Glasgow Coma Scale (GCS) score was 15 (a score of 15 is the highest level of consciousness), his blood glucose was 7.2, and he did not exhibit any signs of trauma. His abbreviated mental test score was 7 out of 10, indicating a degree of altered cognition. An ECG demonstrated atrial fibrillation with a normal heart rate. His admission weight measured 107 kg. At 09:57 the patient required 2 L of nasal cannula oxygen to maintain his oxygen saturations between 88% and 92%. He started to develop agitation associated with an increased respiratory rate at 36 breaths per minute. On auscultation of his chest, he demonstrated widespread coarse crepitation and bilateral wheeze. Throughout he was haemodynamically stable, with a systolic blood pressure between 143 mm Hg and 144 mm Hg and heart rate between 86 beats/min and 95 beats/min. From a neurological standpoint, he had a mild left facial droop, 2/5 power in both lower limbs, 2/5 power in his left upper limb and 5/5 power in his right upper limb. Tone in his left upper limb had increased. This patient was suspected of having COVID-19 pneumonia alongside an ischaemic stroke.
A CT of his brain conducted at 11:38 on 1 April 2020 ( figure 2 ) illustrated an ill-defined hypodensity in the right frontal lobe medially, with sulcal effacement and loss of grey-white matter. This was highly likely to represent acute anterior cerebral artery territory infarction. Furthermore an oval low-density area in the right cerebellar hemisphere, that was also suspicious of an acute infarction. These vascular territories did not entirely correlate with his clinical picture, as limb weakness is not as prominent in anterior cerebral artery territory ischaemia. Therefore this left-sided weakness may have been an amalgamation of residual weakness from his previous stroke, in addition to his acute cerebral infarction. An erect AP chest X-ray with portable equipment ( figure 3 ) conducted on the same day demonstrated patchy peripheral consolidation bilaterally, with no evidence of significant pleural effusion. The pattern of lung involvement raised suspicion of COVID-19 infection, which at this stage was thought to have provoked the acute cerebral infarct. Clinically significant blood results from 1 April 2020 demonstrated a raised C-reactive protein (CRP) at 215 mg/L (normal 0–5 mg/L) and lymphopaenia at 0.5×10 9 (normal 1×10 9 to 3×10 9 ). Other routine blood results are provided in table 1 .
CT imaging of this patients’ brain demonstrating a wedge-shaped infarction of the anterior cerebral artery territory.
Chest X-ray demonstrating the bilateral COVID-19 pneumonia of this patient on admission.
Clinical biochemistry and haematology blood results of the patient
Interestingly the patient, in this case, was clinically assessed in the accident and emergency department on 23 March 2020, 9 days prior to admission, with symptoms of shortness of breath. His blood results from this day showed a CRP of 22 mg/L and a greater lymphopaenia at 0.3×10 9 . He had a chest X-ray ( figure 4 ), which indicated mild radiopacification in the left mid zone. He was initially treated with intravenous co-amoxiclav and ciprofloxacin. The following day he had minimal symptoms (CURB 65 score 1 for being over 65 years). Given improving blood results (declining CRP), he was discharged home with a course of oral amoxicillin and clarithromycin. As national governmental restrictions due to COVID-19 had not been formally announced until 23 March 2020, and inconsistencies regarding personal protective equipment training and usage existed during the earlier stages of this rapidly evolving pandemic, it is possible that this patient contracted COVID-19 within the local community, or during his prior hospital admission. It could be argued that the patient had early COVID-19 signs and symptoms, having presented with shortness of breath, lymphopaenia, and having had subtle infective chest X-ray changes. The patient explained he developed a stagnant productive cough, which began 5 days prior to his attendance to hospital on 23 March 2020. He responded to antibiotics, making a full recovery following 7 days of treatment. This information does not assimilate with the typical features of a COVID-19 infection. A diagnosis of community-acquired pneumonia or infective exacerbation of COPD seem more likely. However, given the high incidence of COVID-19 infections during this patients’ illness, an exposure and early COVID-19 illness, prior to the 23 March 2020, cannot be completely ruled out.
Chest X-ray conducted on prior admission illustrating mild radiopacification in the left mid zone.
On the current admission, this patient was managed with nasal cannula oxygen at 2 L. By the end of the day, this had progressed to a venturi mask, requiring 8 L of oxygen to maintain oxygen saturation. He had also become increasingly drowsy and confused, his GCS declined from 15 to 12. However, the patient was still haemodynamically stable, as he had been in the morning. An arterial blood gas demonstrated a respiratory alkalosis (pH 7.55, pCO 2 3.1, pO 2 6.7 and HCO 3 24.9, lactate 1.8, base excess 0.5). He was commenced on intravenous co-amoxiclav and ciprofloxacin, to treat a potential exacerbation of COPD. This patient had a COVID-19 throat swab on 1 April 2020. Before the result of this swab, an early discussion was held with the intensive care unit staff, who decided at 17:00 on 1 April 2020 that given the patients presentation, rapid deterioration, comorbidities and likely COVID-19 diagnosis he would not be for escalation to the intensive care unit, and if he were to deteriorate further the end of life pathway would be most appropriate. The discussion was reiterated to the patients’ family, who were in agreement with this. Although he had evidence of an ischaemic stroke on CT of his brain, it was agreed by all clinicians that intervention for this was not as much of a priority as providing optimal palliative care, therefore, a minimally invasive method of treatment was advocated by the stroke team. The patient was given 300 mg of aspirin and was not a candidate for fibrinolysis.
The following day, before the throat swab result, had appeared the patient deteriorated further, requiring 15 L of oxygen through a non-rebreather face mask at 60% FiO 2 to maintain his oxygen saturation, at a maximum of 88% overnight. At this point, he was unresponsive to voice, with a GCS of 5. Although, he was still haemodynamically stable, with a blood pressure of 126/74 mm Hg and a heart rate of 98 beats/min. His respiratory rate was 30 breaths/min. His worsening respiratory condition, combined with his declining level of consciousness made it impossible to clinically assess progression of the neurological deficit generated by his cerebral infarction. Moreover, the patient was declining sharply while receiving the maximal ward-based treatment available. The senior respiratory physician overseeing the patients’ care decided that a palliative approach was in this his best interest, which was agreed on by all parties. The respiratory team completed the ‘recognising dying’ documentation, which signified that priorities of care had shifted from curative treatment to palliative care. Although the palliative team was not formally involved in the care of the patient, the patient received comfort measures without further attempts at supporting oxygenation, or conduction of regular clinical observations. The COVID-19 throat swab confirmed a positive result on 2 April 2020. The patient was treated by the medical team under jurisdiction of the hospital palliative care team. This included the prescribing of anticipatory medications and a syringe driver, which was established on 3 April 2020. His antibiotic treatment, non-essential medication and intravenous fluid treatment were discontinued. His comatose condition persisted throughout the admission. Once the patients’ GCS was 5, it did not improve. The patient was pronounced dead by doctors at 08:40 on 5 April 2020.
SARS-CoV-2 is a type of coronavirus that was first reported to have caused pneumonia-like infection in humans on 3 December 2019. 5 As a group, coronaviruses are a common cause of upper and lower respiratory tract infections (especially in children) and have been researched extensively since they were first characterised in the 1960s. 6 To date, there are seven coronaviruses that are known to cause infection in humans, including SARS-CoV-1, the first known zoonotic coronavirus outbreak in November 2002. 7 Coronavirus infections pass through communities during the winter months, causing small outbreaks in local communities, that do not cause significant mortality or morbidity.
SARS-CoV-2 strain of coronavirus is classed as a zoonotic coronavirus, meaning the virus pathogen is transmitted from non-humans to cause disease in humans. However the rapid spread of SARS-CoV-2 indicates human to human transmission is present. From previous research on the transmission of coronaviruses and that of SARS-CoV-2 it can be inferred that SARS-CoV-2 spreads via respiratory droplets, either from direct inhalation, or indirectly touching surfaces with the virus and exposing the eyes, nose or mouth. 8 Common signs and symptoms of the COVID-19 infection identified in patients include high fevers, severe fatigue, dry cough, acute breathing difficulties, bilateral pneumonia on radiological imaging and lymphopaenia. 9 Most of these features were identified in this case study. The significance of COVID-19 is illustrated by the speed of its global spread and the potential to cause severe clinical presentations, which as of April 2020 can only be treated symptomatically. In Italy, as of mid-March 2020, it was reported that 12% of the entire COVID-19 positive population and 16% of all hospitalised patients had an admission to the intensive care unit. 10
The patient, in this case, illustrates the clinical relevance of understanding COVID-19, as he presented with an ischaemic stroke underlined by minimal respiratory symptoms, which progressed expeditiously, resulting in acute respiratory distress syndrome and subsequent death.
Our case is an example of a new and ever-evolving clinical correlation, between patients who present with a radiological confirmed ischaemic stroke and severe COVID-19 pneumonia. As of April 2020, no comprehensive data of the relationship between ischaemic stroke and COVID-19 has been published, however early retrospective case series from three hospitals in Wuhan, China have indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke. 11 These studies have not yet undergone peer review, but they tell us a great deal about the relationship between COVID-19 and ischaemic stroke, and have been used to influence the American Heart Associations ‘Temporary Emergency Guidance to US Stroke Centres During the COVID-19 Pandemic’. 12
The relationship between similar coronaviruses and other viruses, such as influenza in the development of ischaemic stroke has previously been researched and provide a basis for further investigation, into the prominence of COVID-19 and its relation to ischaemic stroke. 3 Studies of SARS-CoV-2 indicate its receptor-binding region for entry into the host cell is the same as ACE2, which is present on endothelial cells throughout the body. It may be the case that SARS-CoV-2 alters the conventional ability of ACE2 to protect endothelial function in blood vessels, promoting atherosclerotic plaque displacement by producing an inflammatory response, thus increasing the risk of ischaemic stroke development. 13
Other hypothesised reasons for stroke development in COVID-19 patients are the development of hypercoagulability, as a result of critical illness or new onset of arrhythmias, caused by severe infection. Some case studies in Wuhan described immense inflammatory responses to COVID-19, including elevated acute phase reactants, such as CRP and D-dimer. Raised D-dimers are a non-specific marker of a prothrombotic state and have been associated with greater morbidity and mortality relating to stroke and other neurological features. 14
Arrhythmias such as atrial fibrillation had been identified in 17% of 138 COVID-19 patients, in a study conducted in Wuhan, China. 15 In this report, the patient was known to have atrial fibrillation and was treated with rivaroxaban. The acute inflammatory state COVID-19 is known to produce had the potential to create a prothrombotic environment, culminating in an ischaemic stroke.
Some early case studies produced in Wuhan describe patients in the sixth decade of life that had not been previously noted to have antiphospholipid antibodies, contain the antibodies in blood results. They are antibodies signify antiphospholipid syndrome; a prothrombotic condition. 16 This raises the hypothesis concerning the ability of COVID-19 to evoke the creation of these antibodies and potentiate thrombotic events, such as ischaemic stroke.
No peer-reviewed studies on the effects of COVID-19 and mechanism of stroke are published as of April 2020; therefore, it is difficult to evidence a specific reason as to why COVID-19 patients are developing neurological signs. It is suspected that a mixture of the factors mentioned above influence the development of ischaemic stroke.
If we delve further into this patients’ comorbid state exclusive to COVID-19 infection, it can be argued that this patient was already at a relatively higher risk of stroke development compared with the general population. The fact this patient had previously had an ischaemic stroke illustrates a prior susceptibility. This patient had a known background of hypertension and atrial fibrillation, which as mentioned previously, can influence blood clot or plaque propagation in the development of an acute ischaemic event. 15 Although the patient was prescribed rivaroxaban as an anticoagulant, true consistent compliance to rivaroxaban or other medications such as amlodipine, clopidogrel, candesartan and atorvastatin cannot be confirmed; all of which can contribute to the reduction of influential factors in the development of ischaemic stroke. Furthermore, the fear of contracting COVID-19, in addition to his vague symptoms, unlike his prior ischaemic stroke, which demonstrated dense left-sided haemiparesis, led to a delay in presentation to hospital. This made treatment options like fibrinolysis unachievable, although it can be argued that if he was already infected with COVID-19, he would have still developed life-threatening COVID-19 pneumonia, regardless of whether he underwent fibrinolysis. It is therefore important to consider that if this patient did not contract COVID-19 pneumonia, he still had many risk factors that made him prone to ischaemic stroke formation. Thus, we must consider whether similar patients would suffer from ischaemic stroke, regardless of COVID-19 infection and whether COVID-19 impacts on the severity of the stroke as an entity.
Having said this, the management of these patients is dependent on the likelihood of a positive outcome from the COVID-19 infection. Establishing the ceiling of care is crucial, as it prevents incredibly unwell or unfit patients’ from going through futile treatments, ensuring respect and dignity in death, if this is the likely outcome. It also allows for the provision of limited or intensive resources, such as intensive care beds or endotracheal intubation during the COVID-19 pandemic, to those who are assessed by the multidisciplinary team to benefit the most from their use. The way to establish this ceiling of care is through an early multidisciplinary discussion. In this case, the patient did not convey his wishes regarding his care to the medical team or his family; therefore it was decided among intensive care specialists, respiratory physicians, stroke physicians and the patients’ relatives. The patient was discussed with the intensive care team, who decided that as the patient sustained two acute life-threatening illnesses simultaneously and had rapidly deteriorated, ward-based care with a view to palliate if the further deterioration was in the patients’ best interests. These decisions were not easy to make, especially as it was on the first day of presentation. This decision was made in the context of the patients’ comorbidities, including COPD, the patients’ age, and the availability of intensive care beds during the steep rise in intensive care admissions, in the midst of the COVID-19 pandemic ( figure 1 ). Furthermore, the patients’ rapid and permanent decline in GCS, entwined with the severe stroke on CT imaging of the brain made it more unlikely that significant and permanent recovery could be achieved from mechanical intubation, especially as the damage caused by the stroke could not be significantly reversed. As hospitals manage patients with COVID-19 in many parts of the world, there may be tension between the need to provide higher levels of care for an individual patient and the need to preserve finite resources to maximise the benefits for most patients. This patient presented during a steep rise in intensive care admissions, which may have influenced the early decision not to treat the patient in an intensive care setting. Retrospective studies from Wuhan investigating mortality in patients with multiple organ failure, in the setting of COVID-19, requiring intubation have demonstrated mortality can be up to 61.5%. 17 The mortality risk is even higher in those over 65 years of age with respiratory comorbidities, indicating why this patient was unlikely to survive an admission to the intensive care unit. 18
Regularly updating the patients’ family ensured cooperation, empathy and sympathy. The patients’ stroke was not seen as a priority given the severity of his COVID-19 pneumonia, therefore the least invasive, but most appropriate treatment was provided for his stroke. The British Association of Stroke Physicians advocate this approach and also request the notification to their organisation of COVID-19-related stroke cases, in the UK. 19
SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is one of seven known coronaviruses that commonly cause upper and lower respiratory tract infections. It is the cause of the 2019–2020 global coronavirus pandemic.
The significance of COVID-19 is illustrated by the rapid speed of its spread globally and the potential to cause severe clinical presentations, such as ischaemic stroke.
Early retrospective data has indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke.
Potential mechanisms behind stroke in COVID-19 patients include a plethora of hypercoagulability secondary to critical illness and systemic inflammation, the development of arrhythmia, alteration to the vascular endothelium resulting in atherosclerotic plaque displacement and dehydration.
It is vital that effective, open communication between the multidisciplinary team, patient and patients relatives is conducted early in order to firmly establish the most appropriate ceiling of care for the patient.
Contributors SB was involved in the collecting of information for the case, the initial written draft of the case and researching existing data on acute stroke and COVID-19. He also edited drafts of the report. MH was involved in reviewing and editing drafts of the report and contributing new data. SP oversaw the conduction of the project and contributed addition research papers.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Next of kin consent obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.
All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .
Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.
Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.
Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.
Original Submission Date Received: .
Find support for a specific problem in the support section of our website.
Please let us know what you think of our products and services.
Visit our dedicated information section to learn more about MDPI.
Exploring stroke patients’ needs: a cultural adaptation and validation of the modified needs assessment questionnaire in a greek context.
2. materials and methods, 2.1. sample & data collection, 2.2. measures, 2.3. data analysis, 3.1. sample’s demographic characteristics, 3.2. scale validation, 3.3. confirmatory factor analysis & reliability analysis, 3.4. construct validity and nonparametric tests, 4. discussion, 5. conclusions, 6. limitations and future research, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.
Sex | % | Phase of Stroke | % | Stroke Severity | % |
---|---|---|---|---|---|
Male | 63.4 | Acute/Subacute | 79 | Minor | 78 |
Female | 36.6 | Chronic | 21 | Moderate | 22 |
Age | % | ||||
18–29 | 4.2 | ||||
30–39 | 7.0 | ||||
40–49 | 9.9 | ||||
50–59 | 18.3 | ||||
60–69 | 42.3 | ||||
70+ | 18.3 |
Factor | Communalities | |||
---|---|---|---|---|
Mobility | Social Functioning | Communication | ||
I need… | 0.812 | 0.713 | ||
0.891 | 0.826 | |||
0.857 | 0.824 | |||
0.891 | 0.901 | |||
0.828 | 0.793 | |||
0.841 | 0.730 | |||
0.928 | 0.862 | |||
0.961 | 0.927 | |||
0.948 | 0.901 | |||
0.867 | 0.758 | |||
0.910 | 0.828 | |||
0.901 | 0.811 | |||
0.916 | 0.840 | |||
0.879 | 0.775 | |||
0.913 | 0.842 | |||
0.877 | 0.777 | |||
0.895 | 0.804 | |||
0.832 | 0.794 | |||
0.874 | 0.848 | |||
0.848 | 0.770 | |||
0.868 | 0.852 | |||
0.926 | 0.893 | |||
0.930 | 0.904 | |||
0.934 | 0.892 | |||
0.946 | 0.906 | |||
0.820 | 0.763 | |||
0.921 | 0.857 | |||
0.836 | 0.860 | |||
0.951 | 0.908 | |||
0.858 | 0.900 | |||
0.870 | 0.951 | |||
Eigenvalues | 16.30 | 6.004 | 3.794 | |
% of variance | 52.15 | 18.78 | 12.32 |
Model | Chi-Square | Df | p-Value | RMSEA | GFI | CFI | TLI | CMIN/df |
---|---|---|---|---|---|---|---|---|
Default model | 640.8 | 431 | 0.0 | 0.1 | 0.4 | 0.3 | 0.2 | 1.5 |
Saturated model | 0.0 | 0 | 1.0 | 1.0 | ||||
Independence model | 746.7 | 465 | 0.0 | 0.1 | 0.3 | 0.0 | 0.0 | 1.6 |
Variables | Cronbach’s Alpha | CR | AVE | Mean Scores | S.D. |
---|---|---|---|---|---|
Mobility | 0.984 | 0.984 | 0.749 | 2.0345 | 1.30571 |
Social Functioning | 0.926 | 0.916 | 0.732 | 1.1127 | 0.55386 |
Communication | 0.975 | 0.993 | 0.873 | 1.2831 | 0.84193 |
The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
Paschalidou, K.; Tsitskari, E.; Tsiakiri, A.; Makri, E.; Vlotinou, P.; Vadikolias, K.; Aggelousis, N. Exploring Stroke Patients’ Needs: A Cultural Adaptation and Validation of the Modified Needs Assessment Questionnaire in a Greek Context. Healthcare 2024 , 12 , 1274. https://doi.org/10.3390/healthcare12131274
Paschalidou K, Tsitskari E, Tsiakiri A, Makri E, Vlotinou P, Vadikolias K, Aggelousis N. Exploring Stroke Patients’ Needs: A Cultural Adaptation and Validation of the Modified Needs Assessment Questionnaire in a Greek Context. Healthcare . 2024; 12(13):1274. https://doi.org/10.3390/healthcare12131274
Paschalidou, Katerina, Efi Tsitskari, Anna Tsiakiri, Evangelia Makri, Pinelopi Vlotinou, Konstantinos Vadikolias, and Nikolaos Aggelousis. 2024. "Exploring Stroke Patients’ Needs: A Cultural Adaptation and Validation of the Modified Needs Assessment Questionnaire in a Greek Context" Healthcare 12, no. 13: 1274. https://doi.org/10.3390/healthcare12131274
Article access statistics, supplementary material.
ZIP-Document (ZIP, 227 KiB)
Mdpi initiatives, follow mdpi.
Subscribe to receive issue release notifications and newsletters from MDPI journals
Academic Support for Nursing Students
No notifications.
Disclaimer: This case study has been written by a student and not our expert nursing writers. View professional sample case studys here.
View full disclaimer
Any opinions, findings, conclusions, or recommendations expressed in this case study are those of the author and do not necessarily reflect the views of NursingAnswers.net. This case study should not be treated as an authoritative source of information when forming medical opinions as information may be inaccurate or out-of-date.
PBL - Stroke Case Study
Info: 3486 words (14 pages) Nursing Case Study Published: 11th Feb 2020
Reference this
Tagged: stroke aphasia
If you need assistance with writing your nursing case study, our professional nursing case study writing service is here to help!
|
|
Smoking | Age > 75 |
Diabetes | Men |
Being overweight/obese | Family history |
Alcohol Use | Genetic predisposition |
To export a reference to this article please select a referencing stye below:
Related Services
Related Content
Content relating to: "aphasia"
Aphasia has many etiologies, such as stroke, infection, brain abscess, brain tumour, nutritional deficiencies, or toxemia. However, the most common cause of aphasia in adults is cerebrovascular accident, which includes several types and classifications for aphasia.
Related Articles
Treatment Methods for Anomia in Aphasia
According to Brookshire (2015), aphasia has many etiologies, such as stroke, infection, brain abscess, brain tumor, nutritional deficiencies, or toxemia. However, the most common cause of aphasia...
Written by: Yung Bing Yong Introduction The brain is the primary organ of the centre nervous system that controls our body and houses our mind. It is metabolically active and dependent on a continuou...
Broca’s Aphasia and Treatment Options for Word Finding Difficulties
A common condition that is an acquired language/communication disorder is known to be Aphasia. This disorder is usually caused from head trauma, brain tumors, stroke, or other neurogenic co...
If you are the original writer of this case study and no longer wish to have your work published on the NursingAnswers.net website then please:
Our academic writing and marking services can help you!
Related Lectures
Study for free with our range of nursing lectures!
Write for Us
Do you have a 2:1 degree or higher in nursing or healthcare?
Study Resources
Free resources to assist you with your nursing studies!
The Ohio State University
What acronym is used to to help identify strokes?
Answer: F.A.S.T – Facial droop, arm drop, speech problems, time. This acronym is universally used to easily teach people how to recognize a stroke. The other acronyms are not used to help people identify strokes.
What are some risk factors for having a stroke? Select all that apply.
Answer: Uncontrolled hypertension, and smoking. Uncontrolled hypertension can damage blood vessels and cause vasoconstriction making it more likely for a clot to form and obstruct the blood flow to the brain. Smoking can also damage blood vessels and cause vasoconstriction, smoking can increase the risk of stroke by up to 50%. Physical activity decreases, not increases, the risk of stroke. Drinking 8 glasses of water is healthy for the body and does not cause an increased risk of strokes.
What is the difference between a TIA and a stroke?
Answer: While both are caused by a lack of blood flow to one or more areas of the brain and they share many of the same clinical manifestations, the symptoms of a TIA resolve in an hour or less.
What is the postictal phase?
Answer: The postictal phase is the period of time immediately following an epileptic seizure and may last from a few minutes to hours. Clinical manifestations often mimic a stroke. Patient history and testing is needed to differentiate the two.
What is the difference between a thrombotic stroke and an embolic stroke?
Answer: A thrombotic stroke is due to thrombi formed in the intracranial vessels or vessels that feed the brain. An embolic stroke happens when fragments break from a thrombus that is formed outside of the brain.
What are two types of hemorrhages that can occur in a hemorrhagic stroke?
Answer: Subarachnoid & intracerebral. Subarachnoid is a bleed that occurs between the brain and the dura while an intracerebral bleed occurs actually in the brain parenchyma. The other answers are classified as ischemic strokes.
IMAGES
VIDEO
COMMENTS
CASE 1. A 20 year old man with no past medical history presented to a primary stroke center with sudden left sided weakness and imbalance followed by decreased level of consciousness. Head CT showed no hemorrhage, no acute ischemic changes, and a hyper-dense basilar artery. CT angiography showed a mid-basilar occlusion.
Other hypothesised reasons for stroke development in COVID-19 patients are the development of hypercoagulability, as a result of critical illness or new onset of arrhythmias, caused by severe infection. Some case studies in Wuhan described immense inflammatory responses to COVID-19, including elevated acute phase reactants, such as CRP and D-dimer.
Read chapter 7 of Patient Management in the Telemetry/Cardiac Step-Down Unit: A Case-Based Approach online now, exclusively on AccessMedicine. AccessMedicine is a subscription-based resource from McGraw Hill that features trusted medical content from the best minds in medicine.
Nurse Laura started an 18 gauge IV in Randall's left AC and started him on a bolus of 500 mL of NS. A blood sample was collected and quickly sent to the lab. Nurse Laura called the Emergency Department Tech to obtain a 12 lead EKG. Pertinent Lab Results for Randall. The physician and the nurse review the labs: WBC 7.3 x 10^9/L. RBC 4.6 x 10^12/L.
Dr. Lee H. Schwamm: This patient with acute stroke benefited from an integrated system of care, 2 which was implemented at a state-certified stroke center 3 and followed stroke-specific dispatch ...
Abstract. Increasing evidence reports a greater incidence of stroke among patients with Coronavirus disease 2019 (COVID-19) than the non-COVID-19 population and suggests that SARS-CoV-2 infection represents a risk factor for thromboembolic and acute ischemic stroke. Elderly people have higher risk factors associated with acute ischemic stroke or embolization vascular events, and advanced age ...
A PFO has been demonstrated in 10%-26% of healthy adults. 14 In young patients who have had a cryptogenic stroke, however, the prevalence is thought to be much higher, for example, 40% in one study. 15 It is thought that a PFO allows microemboli to pass into the systemic circulation leading to a stroke.
In Uganda, literature on stroke in young adults is limited however results of a study done among acute stroke patients admitted to the national referral hospital (Mulago hospital) showed a 30-day mortality of 43.8%. Out of 133 patients, 32 patients (25%) were less than 51 years old. Out of the 56 patients that died, 13 patients (23%) were less ...
Research has shown that approximately 5% of patients will have an ischemic stroke within 7 days after a TIA. In addition, the risk of stroke within 7 days is doubled for patients with TIAs who did not seek treatment. As is the case for many individuals who have a TIA, Patient M did not seek medical attention because the clinical symptoms ...
MC study case Abnormal blood results recommendations • For major bleeding (e.g. intracerebral) within 48 h of administration of R-tpa we recommend: • All patients should be discussed with haematology team urgently • Stop infusion of fibrinolytic drugs and other antithrombotic drugs . • Administer FFP 12 ml/kg. • Administer intravenous tranexamic acid 1 g tds .
Patient Case Presentation. Image courtesy of uofmhealthblogs.org. D.B. is a 72 year old African American female who presented to the ED with complaints of headache, altered mental status as evidenced by confusion and lethargy, slurred speech, right sided weakness, and a facial droop. Symptoms were first noted when patient woke up from a nap ...
Go to Case Rubric. Kanika is a 38-year-old right-handed woman who was working as a social media coordinator for an international organization when she had a stroke in early June. Prior to the stroke, Kanika lived alone and frequently saw her sister and nieces, who lived in a nearby state. Her apartment is on the second floor, and there is no ...
Social work report: Background. Mrs Beryl Brown (01/11/33) is an 85 year old woman who was admitted to the Hume Hospital by ambulance after being found by her youngest daughter lying in front of her toilet. Her daughter estimates that she may have been on the ground overnight. On admission, Mrs Brown was diagnosed with a right sided stroke ...
In this retrospective study, the case records of 1,287 stroke patients admitted to Al-basher Hospital during a three-year period were reviewed. The stroke patient cohort included 60% men and 40% ...
Pathophysiology and clinical presentation. (DiGiovanna, A. G; 1999) Cerebrovascular accidents, also known as strokes, happen when the blood supply becomes occluded in part of the brain. They can be classified as either ischemic, hemorrhagic, or cryptogenic. In ischemic strokes blood supply can be occluded for three different reasons, a vascular ...
Open Dissemination Materials - Groups and Individuals. General Submissions: Presentations (Oral and Poster) Ischemic stroke: A case study.
A 66-year-old man was admitted to hospital with a right frontal cerebral infarct producing left-sided weakness and a deterioration in his speech pattern. The cerebral infarct was confirmed with CT imaging. The only evidence of respiratory symptoms on admission was a 2 L oxygen requirement, maintaining oxygen saturations between 88% and 92%. In a matter of hours this patient developed a greater ...
Our reason for choosing this disorder. Stroke is the leading cause of disability in the United States. As advanced practice nurses, we anticipate caring for those impacted by strokes in many healthcare settings including emergency rooms, acute care, rehab settings, extended care facilities, and in primary care. Early diagnosis and treatment are ...
The sample consisted of 71 stroke patients in acute/subacute phase (79%) and in chronic phase (21%), mostly men (63.4%), aged 60-69 (42.3%). Seventy-eight percent (78%) of them had a minor stroke and 22% moderate stroke. All participants were diagnosed with ischemic stroke and were adults (18 years old and older). ... The study included 71 ...
View professional sample case studys here. View full disclaimer . Any opinions, findings, conclusions, or recommendations expressed in this case study are those of the author and do not necessarily reflect the views of NursingAnswers.net. ... This is the why the patient in this case did not present any sign of stroke at 7:05am on the head CT ...
Answer: Uncontrolled hypertension, and smoking. Uncontrolled hypertension can damage blood vessels and cause vasoconstriction making it more likely for a clot to form and obstruct the blood flow to the brain. Smoking can also damage blood vessels and cause vasoconstriction, smoking can increase the risk of stroke by up to 50%.
Of the 212 515 patients with an internal carotid artery/middle cerebral artery stroke, 49 115 met the inclusion criteria for our study. There were 3490 (7.1%) patients treated with EVT and 45 625 (92.9%) treated with best medical management.