stroke case study essay

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Amani Baidwan, Kendyl Egizi and Alysha Payne

Darrell Jackson, 81 year old male, came to the Emergency Department at Los Robles Hospital by ambulance after he collapsed in a coffee shop. Upon arrival he presented with left sided weakness, facial drooping, and aphasia. He was diagnosed with an ischemic stroke, right humerus head fracture, and right wrist fracture. The priority of care upon initial presentation to the Emergency Department included a CT scan, frequent monitoring of vital signs, starting a peripheral IV, drawing labs, assessing blood glucose, and an EKG. The nurse in the Emergency Department continuously monitored Mr. Jackson’s neurological status, changes in level of consciousness and signs and symptoms of complications.

After much discussion with the family, consent was given for tissue plasminogen activator (tPA). After tPA was given, Mr. Jackson converted to a hemorrhagic stroke, which is one of many risks associated with administration of tPA. He was His computed tomographic scans (CT) revealed intraparenchymal hematoma in both cerebral hemispheres and a large hemorrhage in the left parietal lobe. In the Intensive care Unit, Mr. Jackson was on  a ventilator, had a RASS score of -5 and was only responsive to noxious stimuli. Priority in plan of care included airway management and a CPAP trial to begin weaning protocols. The CPAP trial failed, and a tracheostomy was placed. Mr.Jackson was then transferred to the Progressive Care Unit to continue treatment where the NG tube was removed and a PEG tube was inserted. Mr. Jackson has no known allergies and has a history of hypertension, dementia, Parkinson’s disease, stroke, diabetes, GERD, BPH, hypophosphatemia and anemia.

Collaborative interventions are necessary from all healthcare providers, such as physicians, nurses, physical therapy, occupational therapy, speech therapy, case management and social work, to adequate;y care for Mr. Jackson. Case management has been working closely with the family to provide necessary resources to continue care for Mr. Jackson after discharge from the hospital. Mr. Jackson was discharged home with home health after 3 weeks in the hospital. His condition prior to discharge was as follows: A/O x 3 with mild cognitive deficits, speech impairment and left sided weakness.

Discussion Questions

• What is the difference between an ischemic stroke and hemorrhagic stroke?
• What are some of the risk associated with tissue plasminogen activator (tPA) that the nurse would need to assess for and educate the patient about?
• What are some of the psychological needs the nurse should anticipate for a patient who has experienced a stroke?

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

Share This Book

Case Presentation

Statement of ethics, conflict of interest statement, funding sources, author contributions, ischemic stroke in a 29-year-old patient with covid-19: a case report.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Open the PDF for in another window
• Get Permissions
• Cite Icon Cite
• Search Site

Christian Avvantaggiato , Loredana Amoruso , Maria Pia Lo Muzio , Maria Assunta Mimmo , Michelina Delli Bergoli , Nicoletta Cinone , Luigi Santoro , Lucia Stuppiello , Antonio Turitto , Chiara Ciritella , Pietro Fiore , Andrea Santamato; Ischemic Stroke in a 29-Year-Old Patient with COVID-19: A Case Report. Case Rep Neurol 2 September 2021; 13 (2): 334–340. https://doi.org/10.1159/000515457

Download citation file:

• Ris (Zotero)
• Reference Manager

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 is strongly associated with severe COVID-19 and death. We reported, instead, a case of an ischemic stroke in a young woman during her hospitalization for COVID-19-related pneumonia. A 29-year-old woman presented to the emergency department of our institution with progressive respiratory distress associated with a 2-day history of fever, nausea, and vomiting. The patient was transferred to the intensive care unit (ICU) where she underwent a tracheostomy for mechanical ventilation due to her severe clinical condition and her very low arterial partial pressure of oxygen. The nasopharyngeal swab test confirmed SARS-CoV-2 infection. Laboratory tests showed neutrophilic leucocytosis, a prolonged prothrombin time, and elevated D-dimer and fibrinogen levels. After 18 days, during her stay in the ICU after suspension of the medications used for sedation, left hemiplegia was reported. Central facial palsy on the left side, dysarthria, and facial drop were present, with complete paralysis of the ipsilateral upper and lower limbs. Computed tomography (CT) of the head and magnetic resonance imaging of the brain confirmed the presence of lesions in the right hemisphere affecting the territories of the anterior and middle cerebral arteries, consistent with ischemic stroke. Pulmonary and splenic infarcts were also found after CT of the chest. The age of the patient and the absence of serious concomitant cardiovascular diseases place the emphasis on the capacity of SARS-CoV-2 infection to be an independent cerebrovascular risk factor. Increased levels of D-dimer and positivity to β2-glycoprotein antibodies could confirm the theory of endothelial activation and hypercoagulability, but other mechanisms – still under discussion – should not be excluded.

Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, is characterized by a wide range of symptoms, most of which cause acute respiratory distress syndrome [1, 2], associated with intensive care unit (ICU) admission and high mortality [3]. On March 11, 2020, the large global outbreak of the disease led the World Health Organization (WHO) to declare COVID-19 a pandemic, with 11,874,226 confirmed cases and 545,481 deaths worldwide (July 9, 2020) [4]. In many cases, the clinical manifestations of COVID-19 are characteristic of a mild disease that may, however, worsen to a critical lower respiratory infection [2]. At the onset of the disease, the most frequent symptoms are fever, dry cough, fatigue, and shortness of breath as the infection progresses may appear signs and symptoms of respiratory failure that require ICU admission [5, 6]. Although acute respiratory distress syndrome is the most important cause of ICU admission for COVID-19 patients, several studies have underlined the presence of neurological symptoms such as confusion, dizziness, impaired consciousness, ataxia, seizure, anosmia, ageusia, vision impairment, and stroke [7, 8]. In particular, the state of hypercoagulability in patients affected by COVID-19 favors the formation of small and/or large blood clots in multiple organs, including the brain, potentially leading to cerebrovascular disease (ischemic stroke but also intracranial hemorrhage) [9, 10 ].

We found an interesting case of stroke following a SARS-CoV-2 infection in a young patient. A 29-year-old woman, during her ICU hospitalization for COVID-19-related pneumonia, was diagnosed with ischemic stroke of the right hemisphere, without other cardiac/cerebrovascular risk factors except hypertension. The young age of the patient and the absence of higher cerebrovascular risk factors make the present case very interesting as it can help demonstrate that COVID-19 is an independent risk factor for acute ischemic stroke. In a case series of 214 patients with COVID-19 (mean [SD] age, 52.7 [15.5] years), neurologic symptoms were more common in patients with severe infection who were older than the others [ 11 ]. New-onset CVD was more common in COVID-19 patients who had underlying cerebrovascular risk factors, such as older age (>65 years) [ 12 ], and very few cases of stroke in patients younger than 50 years have been reported [ 12, 13 ]. Our case seems to be the only one younger than 30 years.

On the night between March 19 and 20, 2020, a 29-year-old woman was referred to our hospital “Policlinico Riuniti di Foggia” due to a progressive respiratory distress associated with a 2-day history of fever, nausea, and vomiting. At presentation, the heart rate was 128 bpm, the blood oxygen saturation measured by means of the pulse oximeter was 27%, the respiratory rate was 27 breaths per minute, and the blood pressure was 116/77 mm Hg. The arterial blood gas test showed a pH of 7.52, pO 2 20 mm Hg, and pCO 2 34 mm Hg. The patient was immediately transferred to the ICU where she underwent tracheostomy and endotracheal intubation for mechanical ventilation due to her severe clinical condition and deteriorated pulmonary gas exchange. The diagnosis of COVID-19 was confirmed by PCR on a nasopharyngeal swab.

The family medical history was normal, and the only known pre-existing medical conditions were polycystic ovary syndrome (diagnosed 3 years earlier), conversion disorder, and hypertension (both diagnosed 2 years earlier). Ramipril and nebivolol were prescribed for the high blood pressure treatment, and sertraline was prescribed for the conversion disorder treatment. Drug therapy adherence was inconstant. The patient had no history of diabetes, cardiac pathologies, strokes, transient ischemic attacks, thromboembolic, or other vascular pathologies.

Laboratory tests showed neutrophilic leukocytosis (white blood cell count 14.79 × 10 3 , neutrophil percentage 89.8%, and neutrophil count 13.29 × 10 3 ), a prolonged prothrombin time (15.3 s) with a slightly elevated international normalized ratio (1.38), and elevated D-dimer (6,912 ng/mL) and fibrinogen levels (766 mg/dL). Other findings are shown in Table  1 .

Laboratory test

This pharmacological therapy was set as follows: enoxaparin 6,000 U.I. once a day, piperacillin 4 g/tazobactam 0.5 g twice a day; Kaletra, a combination of lopinavir and ritonavir indicated for human immunodeficiency virus (HIV) infection treatment, 2 tablets twice a day; hydroxychloroquine 200 mg once a day; and furosemide 250 mg, calcium gluconate, and aminophylline 240 mg 3 times a day. No adverse events were reported.

On April 7, 2020, during her stay in the ICU and after suspension of the medications used for sedation, left hemiplegia was reported. The same day, the patient underwent a computed tomography examination of the head, which showed areas of hypodensity in the right hemisphere due to recent cerebral ischemia.

On April 16, 2020, the patient was oriented to time, place, and person. Central facial palsy on the left side, dysarthria, and facial drop were present, with complete paralysis of the ipsilateral upper and lower limbs. The power of all the muscles of the left limbs was grade 0 according to the Medical Research Council (MRC) scale. Deep tendon reflexes were reduced on the left upper limb but hyperactive on the ipsilateral lower limb, with a slight increase in the muscle tonus. The senses of touch, vibration, and pain were reduced on the left side of the face and body.

On the same day, the patient underwent magnetic resonance imaging (MRI) of the brain (Fig.  1 a), showing lesions on the right hemisphere affecting the territories of the anterior and middle cerebral arteries. On May 5, 2020, magnetic resonance angiography showed an early duplication of the sphenoidal segment of the right middle cerebral artery, the branches of which are irregular with rosary bead-like aspects (Fig.  1 d, e); on the same day, the second MRI (Fig.  1 b) confirmed the lesions. Computed tomography of the chest (Fig.  1 c) and abdomen (Fig.  1 f), performed 5 days after the MRI of the brain, showed not only multifocal bilateral ground-glass opacities but also a basal subpleural area of increased density within the left lung (4 × 4 × 3 cm), consistent with a pulmonary infarction. In addition, a vascular lesion, consistent with a splenic infarct, was found in the inferior pole of the spleen. Doppler echocardiography of the hearth showed regular right chambers and left atrium and a slightly hypertrophic left ventricle with normal size and kinetics (ejection fraction: 55%). The age of the patient and the absence of serious concomitant cardiovascular diseases place the emphasis on the capacity of SARS-CoV-2 infection to be an independent cerebrovascular risk factor.

Imaging. a April 16, 2020; MRI of the brain: lesions in the right hemisphere affecting the territories of the anterior and the middle cerebral arteries. b May 5, 2020; MRI of the brain: same lesions in the right hemisphere shown in the previous image. d , e May 5, 2020; MRA showed an early duplication of the sphenoidal segment of the right middle cerebral artery, the branches of which are irregular with rosary bead-like aspect and reduction of blood flow in the middle cerebral artery. c April 20, 2020; CT of the abdomen: vascular lesion, consistent with a splenic infarct, found in the inferior pole of the spleen. f April 20, 2020; CT of the chest: basal subpleural area of increased density within the left lung (4 × 4 × 3 cm), consistent with a pulmonary infarction. MRA, magnetic resonance angiography; CT, computed tomography; MRI, magnetic resonance imaging.

The pandemic outbreak of novel SARS-CoV-2 infection has caused great concern among the services and authorities responsible for public health due to not only the mortality rate but also the danger of filling up hospital capacities in terms of ICU beds and acute non-ICU beds. In this regard, the nonrespiratory complications of COVID-19 should also be taken into great consideration, especially those that threaten patients’ lives and extend hospitalization times. Stroke is one of these complications, since a greater incidence of stroke among patients with COVID-19 than the non-COVID-19 population has been reported, and a preliminary case-control study demonstrated that SARS-CoV-2 infection represents a risk factor for acute ischemic stroke [ 14 ].

We found that the reported case is extremely interesting, since the woman is only 29 years old and considering how stroke in a young patient without other known risk factors is uncommon. Not only elderly people have higher risk factors associated with acute ischemic stroke or embolization vascular events [ 15 ], but it is also true that advanced age is strongly associated with severe COVID-19 and death. The severity of the disease is directly linked to immune dysregulation, cytokine storm, and acute inflammation state, which in turn are more common in patients who present immunosenescence [6].

Inflammation plays an important role in the occurrence of cardiovascular and cerebrovascular diseases since it favors atherosclerosis and affects plaque stability [ 16 ]. The ischemic stroke of the 29-year-old woman does not appear to be imputable to emboli originating a pre-existing atheromatous plaque, both for the age of the patient and for the absence of plaques at the Doppler ultrasound study of the supra-aortic trunks.

Most likely, COVID-19-associated hypercoagulability and endothelial dysfunction are the causes of ischemic stroke, as suggested by other studies and case reports [ 10, 13, 17 ]. Although the mechanisms by which SARS-CoV-2 infection leads to hypercoagulability are still being studied, current knowledge suggests that cross talk between inflammation and thrombosis has a crucial role [ 18 ]. The release of inflammatory cytokines leads to the activation of epithelial cells, monocytes, and macrophages. Direct infection of endothelial cells through the ACE2 receptor also leads to endothelial activation and dysfunction, expression of tissue factor, and platelet activation and increased levels of VWF and FVIII, all of which contribute to thrombin generation and fibrin clot formation [ 17 ]. The 29-year-old patient showed an increased level of D-dimer, which is a degradation product of cross-linked fibrin, indicating a global activation of hemostasis and fibrinolysis and conforming to the hypothesis of COVID-19-associated hypercoagulability. Endothelial activation and hypercoagulability are also confirmed by positivity to β2 glycoprotein antibodies. Anticardiolipin antibody and/or β2 glycoprotein antibody positivity has been reported in a few studies [ 17, 19, 20 ]. In addition, widespread thrombosis in SARS-CoV-2 infection could also be caused by neutrophil extracellular traps (NETs). Neutrophilia [ 21 ] and an elevated neutrophil-lymphocyte ratio [ 22 ] have been reported by numerous studies as predictive of worse disease outcomes, and recently, the contribution of NETs in the pathophysiology of COVID-19 was reported [ 23 ]. Thrombogenic involvement of NETs has been described in various settings of thrombosis, including stroke, myocardial infarction, and deep vein thrombosis [ 24 ]. The high neutrophil count found in our case does not exclude the hypothesis that NETs are involved in the pathogenesis of ischemic stroke.

Ischemic stroke in young patients without pre-existing cerebrovascular risk factors is very unusual. In this regard, our case of an ischemic stroke, reported in a 29-year-old woman, is very interesting. Although it is not possible to determine precisely when the thromboembolic event occurred, our case of stroke during COVID-19-related pneumonia seems to confirm that COVID-19 is an independent risk factor for acute ischemic stroke. The mechanisms by which coronavirus disease leads to stroke are still under study, but it is clear that hypercoagulability and endothelial activation play a key role. Testing for SARS-CoV-2 infection should be considered for patients who develop neurologic symptoms, but it is equally important to monitor COVID-19 patients during their hospitalization to find any neurological sign or symptom in a timely manner. Our case suggests that discovering neurological deficits in sedated patients promptly can be very difficult; for this reason, sedation in mechanically ventilated patients has to be considered only if strictly necessary. Performing serial laboratory testing and waking up the patient as soon as clinical conditions allow are strategies that should be taken into account.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.

The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

No funding was received for the publication of this case report.

All authors agree with the contents of the manuscript and were fully involved in the study and preparation of the manuscript. All authors read and approved the final version of the manuscript. M.A. Mimmo, M.P. Lo Muzio, M. Delli Bergoli, and L. Amoruso collected the data. C. Avvantaggiato wrote the manuscript with support of N. Cinone, L. Santoro, and C. Ciritella. C. Avvantaggiato, A. Turitto, and L. Stuppiello researched and discussed the neurophysiological principles of this study. P. Fiore and A. Santamato supervised the project.

Email alerts

Citing articles via, suggested reading.

• Online ISSN 1662-680X

INFORMATION

• Contact & Support
• Information & Downloads
• Rights & Permissions
• Terms & Conditions
• Catalogue & Pricing
• Policies & Information
• People & Organization
• Stay Up-to-Date
• Regional Offices
• Community Voice

SERVICES FOR

• Researchers
• Healthcare Professionals
• Patients & Supporters
• Health Sciences Industry
• Medical Societies
• Agents & Booksellers

Karger International

• S. Karger AG
• P.O Box, CH-4009 Basel (Switzerland)
• Allschwilerstrasse 10, CH-4055 Basel
• Tel: +41 61 306 11 11
• Fax: +41 61 306 12 34
• Contact: Front Office
• Experience Blog
• Privacy Policy
• Terms of Use

This Feature Is Available To Subscribers Only

Sign In or Create an Account

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Mol Sci

Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives

Stroke is the second leading cause of death and a major contributor to disability worldwide. The prevalence of stroke is highest in developing countries, with ischemic stroke being the most common type. Considerable progress has been made in our understanding of the pathophysiology of stroke and the underlying mechanisms leading to ischemic insult. Stroke therapy primarily focuses on restoring blood flow to the brain and treating stroke-induced neurological damage. Lack of success in recent clinical trials has led to significant refinement of animal models, focus-driven study design and use of new technologies in stroke research. Simultaneously, despite progress in stroke management, post-stroke care exerts a substantial impact on families, the healthcare system and the economy. Improvements in pre-clinical and clinical care are likely to underpin successful stroke treatment, recovery, rehabilitation and prevention. In this review, we focus on the pathophysiology of stroke, major advances in the identification of therapeutic targets and recent trends in stroke research.

1. Introduction

Stroke is a neurological disorder characterized by blockage of blood vessels. Clots form in the brain and interrupt blood flow, clogging arteries and causing blood vessels to break, leading to bleeding. Rupture of the arteries leading to the brain during stroke results in the sudden death of brain cells owing to a lack of oxygen. Stroke can also lead to depression and dementia.

Until the International Classification of Disease 11 (ICD-11) was released in 2018, stroke was classified as a disease of the blood vessels. Under the previous ICD coding rationale, clinical data generated from stroke patients were included as part of the cardiovascular diseases chapter, greatly misrepresenting the severity and specific disease burden of stroke. Due to this misclassification within the ICD, stroke patients and researchers did not benefit from government support or grant funding directed towards neurological disease. After prolonged advocacy from a group of clinicians, the true nature and significance of stroke was acknowledged in the ICD-11; stroke was re-categorized into the neurological chapter [ 1 ]. The reclassification of stroke as a neurological disorder has led to more accurate documentation of data and statistical analysis, supporting improvements in acute healthcare and acquisition of research funding for stroke.

2. Epidemiology of Stroke

Stroke is the second leading cause of death globally. It affects roughly 13.7 million people and kills around 5.5 million annually. Approximately 87% of strokes are ischemic infarctions, a prevalence which increased substantially between 1990 and 2016, attributed to decreased mortality and improved clinical interventions. Primary (first-time) hemorrhages comprise the majority of strokes, with secondary (second-time) hemorrhages constituting an estimated 10–25% [ 2 , 3 ]. The incidence of stroke doubled in low-and-middle income countries over 1990–2016 but declined by 42% in high-income countries over the same period. According to the Global Burden of Disease Study (GBD), although the prevalence of stroke has decreased, the age of those affected, their sex and their geographic location mean that the socio-economic burden of stroke has increased over time [ 3 ].

Age-specific stroke : The incidence of stroke increases with age, doubling after the age of 55 years. However, in an alarming trend, strokes in people aged 20–54 years increased from 12.9% to 18.6% of all cases globally between 1990 and 2016. Nevertheless, age-standardized attributable death rates decreased by 36.2% over the same period [ 3 , 4 , 5 ]. The highest reported stroke incidence is in China, where it affects an estimated 331–378 individuals per 100,000 life years. The second-highest rate is in eastern Europe (181–218 per 100,000 life years) and the lowest in Latin America (85–100 per 100,000 life years) [ 3 ].

Gender-specific stroke : The occurrence of stroke in men and women also depends on age. It is higher at younger ages in women, whereas incidence increases slightly with older age in men. The higher risk for stroke in women is due to factors related to pregnancy, such as preeclampsia, contraceptive use and hormonal therapy, as well as migraine with aura. Atrial fibrillation increases stroke risk in women over 75 years by 20%. Based on the National Institutes of Health Stroke Scale (0 = no stroke, 1–4 = minor stroke, 5–15 = moderate stroke, 15–20 = moderate/severe stroke, 21–42 = severe stroke), mean stroke severity was estimated at 10 for women and 8.2 for men. Both brain infarction and intracerebral hemorrhage (ICH) are common in men, but cardioembolic stroke, a more severe form of stroke, is more prevalent among women. The fatality rate for stroke is also higher among women [ 5 , 6 , 7 ]. Women live longer than men, which is one reason for their higher incidence of stroke; another important concern is women’s delay in accepting help for ongoing symptoms [ 8 ]. For men, the most common causes of stroke are tobacco smoking, excessive alcohol consumption, myocardial infarction and arterial disorders [ 9 ].

Geographic and racial variation : As noted earlier, stroke incidence varies considerably across the globe. A global population-based study of the prevalence of stroke and related risks examined demography, behavior, physical characteristics, medical history and laboratory reports, and revealed the contribution of exposure to air pollution and particulate matter to stroke mortality [ 10 ]. Another population-based study, conducted in north-eastern China, is thought to be broadly representative of the disease situation in developing countries. It found hypertension to be a statistically significant risk for stroke, specifically ischemic stroke [ 11 ]. A study conducted in the United States (US) also identified hypertension as a major cause of stroke and described geographical variation in symptomatic intensity in stroke sufferers. Insufficient physical activity, poor food habits and nicotine and alcohol consumption were considered added risks [ 12 ]. Differences in exposure to environmental pollutants, such as lead and cadmium, also influenced stroke incidences across regions. This study also revealed differences in stroke incidence between non-Hispanic white and black populations aged 40–50 years [ 13 ].

Socioeconomic variation : There is a strong inverse relationship between stroke and socioeconomic status, attributable to inadequate hospital facilities and post-stroke care among low-income populations [ 14 ]. A case study conducted in the US showed that people with high financial status had better stroke treatment options than deprived individuals [ 15 ]. A study in China linked low income and lack of health insurance to prevention of secondary stroke attack [ 16 ]. Research conducted in Austria associated level of education with take-up of treatments such as echocardiography and speech therapy; however, there was no difference in administration of thrombolysis, occupational therapy, physiotherapy or stroke care for secondary attack by socioeconomic status [ 17 ]. Similarly, in the Scottish healthcare system, basic treatments like thrombolysis were provided irrespective of the economic status of patients [ 18 ].

3. Pathophysiology of Stroke

Stroke is defined as an abrupt neurological outburst caused by impaired perfusion through the blood vessels to the brain. It is important to understand the neurovascular anatomy to study the clinical manifestation of the stroke. The blood flow to the brain is managed by two internal carotids anteriorly and two vertebral arteries posteriorly (the circle of Willis). Ischemic stroke is caused by deficient blood and oxygen supply to the brain; hemorrhagic stroke is caused by bleeding or leaky blood vessels.

Ischemic occlusions contribute to around 85% of casualties in stroke patients, with the remainder due to intracerebral bleeding. Ischemic occlusion generates thrombotic and embolic conditions in the brain [ 19 ]. In thrombosis, the blood flow is affected by narrowing of vessels due to atherosclerosis. The build-up of plaque will eventually constrict the vascular chamber and form clots, causing thrombotic stroke. In an embolic stroke, decreased blood flow to the brain region causes an embolism; the blood flow to the brain reduces, causing severe stress and untimely cell death (necrosis). Necrosis is followed by disruption of the plasma membrane, organelle swelling and leaking of cellular contents into extracellular space [ 20 ], and loss of neuronal function. Other key events contributing to stroke pathology are inflammation, energy failure, loss of homeostasis, acidosis, increased intracellular calcium levels, excitotoxicity, free radical-mediated toxicity, cytokine-mediated cytotoxicity, complement activation, impairment of the blood–brain barrier, activation of glial cells, oxidative stress and infiltration of leukocytes [ 21 , 22 , 23 , 24 , 25 ].

Hemorrhagic stroke accounts for approximately 10–15% of all strokes and has a high mortality rate. In this condition, stress in the brain tissue and internal injury cause blood vessels to rupture. It produces toxic effects in the vascular system, resulting in infarction [ 26 ]. It is classified into intracerebral and subarachnoid hemorrhage. In ICH, blood vessels rupture and cause abnormal accumulation of blood within the brain. The main reasons for ICH are hypertension, disrupted vasculature, excessive use of anticoagulants and thrombolytic agents. In subarachnoid hemorrhage, blood accumulates in the subarachnoid space of the brain due to a head injury or cerebral aneurysm ( Figure 1 ) [ 27 , 28 ].

Molecular mechanism of stroke.

4. Risk Factors for Stroke

As noted earlier, the risk of stroke increases with age and doubles over the age of 55 years in both men and women. Risk is increased further when an individual has an existing medical condition like hypertension, coronary artery disease or hyperlipidemia. Nearly 60% of strokes are in patients with a history of transient ischemic attack (TIA). Some of the risk factors for stroke are modifiable, and some are non-modifiable ( Figure 2 ).

Risk factors associated with stroke.

4.1. Non-Modifiable Risk Factors

These include age, sex, ethnicity, TIA and hereditary characteristics. In the US in 2005, the average age of incidence of stroke was 69.2 years [ 2 , 29 , 30 ]. Recent research has indicated that people aged 20–54 years are at increasing risk of stroke, probably due to pre-existing secondary factors [ 31 ]. Women are at equal or greater risk of stroke than men, irrespective of age [ 32 ]. US research shows that Hispanic and black populations are at higher risk of stroke than white populations; notably, the incidence of hemorrhagic stroke is significantly higher in black people than in age-matched white populations [ 33 , 34 , 35 ].

Transient ischemic attack is classified as a mini stroke; the underlying mechanism is the same as for full-blown stroke. In TIA, the blood supply to part of the brain is blocked temporarily. It acts as a warning sign before the actual event, providing an opportunity to change lifestyle and commence medications to reduce the chance of stroke [ 36 , 37 ].

Genetics contribute to both modifiable and non-modifiable risk factors for stroke. Genetic risk is proportional to the age, sex and race of the individual [ 38 , 39 ], but a multitude of genetic mechanisms can increase the risk of stroke. Firstly, a parental or family history of stroke increases the chance of an individual developing this neurological disorder. Secondly, a rare single gene mutation can contribute to pathophysiology in which stroke is the primary clinical manifestation, such as in cerebral autosomal dominant arteriopathy. Thirdly, stroke can be one of many after-effects of multiple syndromes caused by genetic mutation, such as sickle cell anemia. Fourthly, some common genetic variants are associated with increased stroke risk, such as genetic polymorphism in 9p21 [ 40 ]. A genome-wide association study of stroke showed high heritability (around 40%) for large blood vessel disease, and low heritability (16.7%) for small vessel disorders. Recent evidence suggests that studying heritability will improve the understanding of stroke sub-types, improve patient management and enable earlier and more efficient prognosis [ 5 , 41 ].

4.2. Modifiable Risk Factors

These are of paramount importance, because timely and appropriate medical intervention can reduce the risk of stroke in susceptible individuals. The major modifiable risk factors for stroke are hypertension, diabetes, lack of physical exercise, alcohol and drug abuse, cholesterol, diet management and genetics.

Hypertension : It is one of the predominant risk factors for stroke. In one study, a blood pressure (BP) of at least 160/90 mmHg and a history of hypertension were considered equally important predispositions for stroke, with 54% of the stroke-affected population having these characteristics [ 42 , 43 ]. BP and prevalence of stroke are correlated in both hypertensive and normal individuals. A study reported that a 5–6 mm Hg reduction in BP lowered the relative risk of stroke by 42% [ 44 ]. Randomized trials of interventions to reduce hypertension in people aged 60+ have shown similar results, lowering the incidences of symptoms of stroke by 36% and 42%, respectively [ 45 , 46 ].

Diabetes : It doubles the risk of ischemic stroke and confers an approximately 20% higher mortality rate. Moreover, the prognosis for diabetic individuals after a stroke is worse than for non-diabetic patients, including higher rates of severe disability and slower recovery [ 47 , 48 ]. Tight regulation of glycemic levels alone is ineffective; medical intervention plus behavioral modifications could help decrease the severity of stroke for diabetic individuals [ 49 ].

Atrial fibrillation (AF) : AF is an important risk factor for stroke, increasing risk two- to five-fold depending upon the age of the individual concerned [ 50 ]. It contributes to 15% of all strokes and produces more severe disability and higher mortality than non-AF-related strokes [ 51 ]. Research has shown that in AF, decreased blood flow in the left atrium causes thrombolysis and embolism in the brain. However, recent studies have contradicted this finding, citing poor evidence of sequential timing of incidence of AF and stroke, and noting that in some patients the occurrence of AF is recorded only after a stroke. In other instances, individuals harboring genetic mutations specific to AF can be affected by stroke long before the onset of AF [ 52 , 53 ]. Therefore, we need better methods of monitoring the heart rhythms that are associated with the vascular risk factors of AF and thromboembolism.

Hyperlipidemia : It is a major contributor to coronary heart disease, but its relationship to stroke is complicated. Total cholesterol is associated with risk of stroke, whereas high-density lipoprotein (HDL) decreases stroke incidence [ 54 , 55 , 56 ]. Therefore, evaluation of lipid profile enables estimation of the risk of stroke. In one study, low levels of HDL (<0.90 mmol/L), high levels of total triglyceride (>2.30 mmol/L) and hypertension were associated with a two-fold increase in the risk of stroke-related death in the population [ 55 ].

Alcohol and drug abuse : The relationship between stroke risk and alcohol intake follows a curvilinear pattern, with the risk related to the amount of alcohol consumed daily. Low to moderate consumption of alcohol (≤2 standard drinks daily for men and ≤1 for women) reduces stroke risk, whereas high intake increases it. In contrast, even low consumption of alcohol escalates the risk of hemorrhagic stroke [ 57 , 58 , 59 ]. Regular use of illegitimate substances such as cocaine, heroin, phencyclidine (PCP), lysergic acid diethylamide (LSD), cannabis/marijuana or amphetamines is related to increased risk of all subtypes of strokes [ 60 ]. Illicit drug use is a common predisposing factor for stroke among individuals aged below 35 years. US research showed that the proportion of illicit drug users among stroke patients aged 15–44 years was six times higher than among age-matched patients admitted with other serious conditions [ 61 ]. However, there is no strong evidence to confirm these findings, and the relationship between these drugs and stroke is anecdotal [ 62 ].

Smoking : Tobacco smoking is directly linked to increased risk of stroke. An average smoker has twice the chance of suffering from a stroke of a non-smoker. Smoking contributes to 15% of stroke-related mortality. Research suggests that an individual who stops smoking reduces the relative risk of stroke, while prolonged second-hand smoking confers a 30% elevation in the risk of stroke [ 63 , 64 , 65 ].

Insufficient physical inactivity and poor diet are associated with increased risk for stroke. Lack of exercise increases the chances of stroke attack in an individual. Insufficient physical activity is also linked to other health issues like high BP, obesity and diabetes, all conditions related to high stroke incidence [ 66 , 67 ]. Poor diet influences the risk of stroke, contributing to hypertension, hyperlipidemia, obesity and diabetes. Certain dietary components are well known to heighten risk; for example, excessive salt intake is linked to high hypertension and stroke. Conversely, a diet high in fruit and vegetables (notably, the Mediterranean diet) has been shown to decrease the risk of stroke [ 68 , 69 , 70 , 71 , 72 ].

5. Animal Models of Stroke

Animal models usually used for research include induced, spontaneous, negative and orphan models. In the induced model, a disease condition is induced in the animal with a view to studying the effects, whereas in the spontaneous model, an animal is selected with a similar disease state naturally present in the model. Negative animal models are used to study the resistance mechanisms underlying a particular disease condition. Orphan models are deployed to understand the pathology of a newly characterized disease in human subjects [ 73 , 74 ].

Many animal models have been developed to study the pathophysiology associated with stroke; they offer several advantages over studying stroke in humans or in vitro. The nature of stroke in humans is unpredictable, with diverse clinical manifestation and localization, whereas animal models are highly predictable and reproducible. Pathophysiological investigation often requires direct access to brain tissue, which is possible with animal models but not in humans. Moreover, current imaging techniques are unable to characterize events occurring within the first few minutes of a stroke. Finally, some aspects of stroke, such as vasculature and perfusion, cannot be studied in in vitro models [ 75 ]. Different stroke models used in animals are described in the session below ( Table 1 ).

Advantages and disadvantages of the stroke models.

The intraluminal suture MCAo model : The middle cerebral artery (MCA) is vulnerable to ischemic insult and occlusion in humans, accounting for 70% of stroke-related disability. This disease model has been widely studied in rat and mouse models, with more than 2600 experiments conducted [ 76 , 77 ]. The MCAo procedure is minimally invasive; it involves occlusion of the carotid artery by insertion of a suture until it interrupts blood flow to the MCA. This procedure is applied for time periods such as 60 or 90 min or permanently, to induce infarction, and has a success rate of 88–100% in rats and mice [ 78 ]. The most commonly used animal for studying pre-clinical stroke is the Sprague–Dawley rat, which has a small infarct volume [ 79 ]. In mice, C57BL/6 and SV129 are commonly used to introduce MCA infarction. The reproducibility of the technique depends on a multitude of factors, such as the animal strain, suture diameter, body weight and age. The advantage of this model is that it mimics the human ischemic stroke and displays similar penumbra [ 80 ]. The MCAo model is appropriate for reproducing ischemic stroke and associated clinical manifestations such as neuronal cell death, cerebral inflammation and blood–brain barrier damage [ 75 ].

Craniectomy model : This model uses a surgical procedure for inducing occlusion in the artery. In this technique, a neurological deficit can be induced in mice by electrocoagulation causing permanent insult or a microaneurysm until blood flow is interrupted. Alternatively, three-vessel occlusion is used, reducing the blood flow and resulting in damaged tissue. The infarct volume differs depending on whether the occlusion is permanent or transient [ 81 , 82 , 83 ]. A study conducted in neonatal P14–P18 rats mimicked pediatric stroke in a younger human population; a 3-h occlusion was performed to induce lesions affecting 40–50% of the brain [ 84 ]. Similarly, in P7 rats, oedema formation was observed in the MCA, followed by microglial infiltration. The P12 CB-17 is another animal model used for stroke research, mainly due to low variability in occlusion insult to the brain [ 85 ]. The other advantages of this model include reproducible infarct size and neurofunctional deficits, reduced mortality and visual ratification. The CB-17 model was successfully used to reproduce cerebral infarction and long-term survival rate, and to study ischemic reperfusion. Researchers showed that reperfusion supports neuron survival, rescues vascular phenotypes and is associated with functional recovery after stroke [ 86 ].

The Levine–Rice model : It involves histological examination and behavioral tests in rat pups, and it is used to study neonatal hypoxic-ischemic stroke [ 87 ]. In this model, a unilateral ligation is followed by reperfusion and recovery. Later, the animal is placed in a hypoxic chamber to understand neonatal stroke pathophysiology as well as regenerative and rehabilitative therapeutic possibilities. P7 rat animal models are commonly used to study the clinical manifestations of hypoxic-ischemic injury [ 88 , 89 , 90 ].

Photo-thrombosis model : This model is based on photo-oxidation of the vasculature leading to lesion formation in the cortex and striatum. In this method, the skull is irradiated with a photoactive dye that causes endothelial damage, intraparenchymal vessel aggregation and platelet stimulation in the affected area. It is injected intraperitoneally in mice and intravenously in rats [ 91 ]. This model is highly reproducible, with a low mortality rate and no surgery. The pathophysiology of this method is slightly different to that seen in human stroke due to little collateral blood flow or formation of ischemic penumbra. However, recent researchers modified the photothrombotic ischemia model to include hypoperfusion in an attempt to mimic penumbra. It has also been deployed in freely moving mice to evaluate the development of motor cortex ischemia and motor deficits. This model permits assessment of the ongoing infarction and improves our understanding of the neuronal insult and repair process [ 92 , 93 ].

Endothelin-1 model: Endothelin-1 (ET-1) : ET-1 is a small peptide molecule produced by smooth muscle cells and the endothelium. It is a paracrine factor that restricts the vascular system through cell-specific receptors. Ischemic lesion is induced by stereotaxic injection of ET-1 directly into the exposed MCA in the intracerebral or cortex region [ 94 ]. ET-1 administration was observed to cause 70–90% reduction in cerebral blood flow, followed by reperfusion [ 95 ]. This technique is minimally invasive, has a low death rate and can be applied to deep and superficial brain regions. It is appropriate for long-term lesion studies, and the lesion size can be controlled by regulating ET-1 concentration, which is critical for reproducibility [ 95 ]. ET-1 is expressed by both neurons and astrocytes, which may decrease the stringency of interpretation of neuronal dysfunction in stroke [ 96 ]. A study in juvenile P21 rats used ET-1 to induce focal lesion in the striatum [ 97 ]. Similarly, aged P12 and P25 rats showed neuronal damage and lesion formation after injection of ET-1 into the hippocampus [ 98 ].

The embolic stroke model : It includes microsphere, macrosphere and thromboembolic models. The microsphere model involves introduction of spheres of diameter 20–50 μm into the circulatory system using a microcatheter to form multifocal infarcts [ 99 ]. Macrospheres are 100–400 μm in diameter and introduced into the intracerebral artery (ICA) to produce reproducible lesions in the MCA [ 100 ]. In the thromboembolic model, thrombin is directly injected to form clots in the ICA or MCA. The volume of the infarct depends upon the size of the clot formed [ 101 ]. This model closely resembles the type of stroke seen in humans. Prior study of clots induced by this model in mice have showed that they are mainly comprised of polymerized fibrin with few cells and platelets present, and 75% of clots exhibit platelet/fibrin build-up and deposition of neutrophils, monocytes and erythrocytes [ 102 ].

Neurorehabilitation in animal models : Various rehabilitative devices and forced training strategies have been deployed in stroke-affected animals to study neurological behavior. Robotic and electric devices have also been developed for training purposes in animal models to evaluate the functionality and effectiveness of the rehabilitation process. Similarly, forced exercise regimes, such as running on a treadmill or task-oriented motor training, are used to study rehabilitation scope in humans. Housing environments that provide social, motor and sensory stimuli and support cell engraftment, creating a more realistic approximation of human treatment, can be tested using animal models [ 103 , 104 , 105 ].

Animal models in biomaterial testing : Animal models have been well characterized for the study of brain tissues via brain atlases ( http://www.med.harvard.edu/AANLIB/ , https://portal.brain-map.org ) for the required species. Stereotaxic techniques are utilized to introduce biomaterials or cells into particular coordinates of the target tissue. Microlesions can be studied precisely, and targeted localization can be confirmed using magnetic resonance imaging (MRI)-based lesion cartography [ 106 , 107 , 108 ].

6. Prevention and Treatment Strategies for Stroke

Stroke prevention involves modifying risk factors within a population or individuals, while stroke management depends on treating its pathophysiology. Despite an enormous amount of research into stroke over the last two decades, no simple means of treating or preventing all the clinical causes of stroke has been established. The overall direction of current stroke research is to generate novel therapies that modulate factors leading to primary and secondary stroke. Recent and current strategies for stroke prevention and treatment are discussed below ( Figure 3 ).

Stroke therapy. This represents the overall process to manage the incidence of stroke.

Excitotoxicity : Neuronal death is a key manifestation of stroke. A key reason for this phenomenon is neuronal depolarization and inability to maintain membrane potential within the cell. This process is mediated by glutamate receptors N-methyl-D-aspartate (NMDA) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), which were among the first neuroprotective agents tested in stroke prevention. However, the untimely release of glutamate overpowers the system that removes glutamate from the cell and causes abnormal release of NMDA and AMPA molecules, leading to uninhibited calcium influx and protein damage. As a result, these agents have not been shown to reduce neuronal death in human subjects. Targeting the molecular pathways downstream of excitotoxicity signaling, rather than directly targeting glutamatergic signaling, might reduce the side effects of the process [ 109 , 110 ].

Gamma aminobutyric acid (GABA) agonists : Clomethiazole is a GABA agonist that has been tested for its ability to improve stroke symptoms in patients, but failed to reduce the toxicity induced by the glutamate receptor [ 111 ].

Sodium (Na + ) channel blockers : Na + channel blockers have been used as neuroprotective agents in various animal models of stroke. They prevent neuronal death and reduce white matter damage. Many voltage-gated Na + channel blockers have been tested in clinical trials, but most have proved to be ineffective [ 112 ]. Mexiletine is a neuroprotectant and Na + channel blocker that proved effective in grey and white matter ischemic stroke, though further evaluation is required to confirm its role [ 113 ]. Lubeluzole was shown to reduce mortality in stroke in initial clinical trials, but successive trials failed to reproduce similar outcomes. Similarly, sipatrigine is a Na + and Ca 2+ channel blocker which failed in a Phase II clinical trial in stroke patients. Amiodarone was shown to aggravate brain injury due to defective transportation and accumulation of Na + ions in the brain after stroke [ 114 ].

Calcium (Ca 2+ ) channel blockers : Voltage-dependent Ca 2+ ion channel blockers have been shown to decrease the ischemic insult in animal models of brain injury. The Ca 2+ ion chelator DP-b99 proved efficient and safe in Phase I and II clinical trials when administered to stroke patients. Similarly, Phase II trials significantly improved clinical symptoms in stroke patients treated within 12 h of onset [ 115 ]. In another study, Ca 2+ channel blockers reduced the risk of stroke by 13.5% in comparison to diuretics and β-blockers [ 116 ].

Antioxidants : Reactive oxygen species produced in the normal brain are balanced by antioxidants generated in a responsive mechanism. However, in the ischemic stroke model, excess production of free radicals and inactivation of detoxifying agents cause redox disequilibrium. This phenomenon leads to oxidative stress, followed by neuronal injury. Therefore, antioxidants are employed in treatment of acute stroke to inhibit or scavenge free radical production and degrade free radicals in the system. In one study, antioxidant AEOL 10,150 (manganese (III) meso-tetrakis (di-N-ethylimidazole) porphyrin) effectively regulated the gene expression profiles specific to inflammation and stress response to decrease the ischemic damage and reperfusion in stroke patients [ 117 ]. In another, deferoxamine was shown to regulate the expression of hypoxia-inducible factor-1, a transcriptional factor regulated by oxygen levels, which in turn switched on other genes like vascular endothelial growth factor and erythropoietin. This mechanism, studied in an animal stroke model, proved beneficial in reducing lesion size and improving sensorimotor capabilities [ 118 , 119 ]. Similarly, NXY-059 compound acts as a scavenger to eliminate free radicals and decrease neurological deficits. The Stroke-Acute-Ischemic-NXY-Treatment-I (SAINT) clinical trial showed the efficacy and safety of NXY-059, but SAINT II failed to reproduce the positive effect of this drug in stroke patients [ 120 , 121 ]. In another study, researchers employed intravenous injection of antioxidants directly into mice brains to understand the benefits of route of administration. This method reduced neurological defects, but had minimal influence on brain damage [ 122 ].

6.1. Reperfusion

The intravenous thrombolytics (IVT) : The IVT treatment paradigm was originally developed to treat coronary thrombolysis but was found to be effective in treating stroke patients. The efficiency of thrombolytic drugs depends on factors including the age of the clot, the specificity of the thrombolytic agent for fibrin and the presence and half-life of neutralizing antibodies [ 123 ]. The drugs used in IVT treatment aim to promote fibrinolysin formation, which catalyzes the dissolution of the clot blocking the cerebral vessel. The most effective IVT drug, recombinant tissue plasminogen activator (rt-PA, or alteplase), was developed from research conducted by the US National Institute of Neurological Disorders and Stroke (NINDS) [ 124 ]. However, European Cooperative Acute Stroke Study (ECASS and ECASS II) researchers were unable to reproduce NINDS’ results. Later, it was found that this drug was effective in reducing clot diameter in stroke patients within three hours of incidence. The Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) confirmed the efficacy and safety of alteplase within the designated time frame [ 125 ]. Another category of thrombolytics, consisting of fibrin and non-fibrin drugs, is used for treatment of stroke symptoms. Fibrin activators like alteplase, reteplase and tenecteplase convert plasminogen to plasmin directly, whereas non-fibrin activators like the drugs streptokinase and staphylokinase do so indirectly [ 123 ].

Intra-arterial thrombolysis (IAT) : IAT is another approach designed to combat acute stroke. This treatment is most effective in the first six hours of onset of MCA occlusion, and requires experienced clinicians and angiographic techniques [ 115 ]. Prolyse in Acute Cerebral Thromboembolism II (PROACT II) and Middle Cerebral Artery Embolism Local Fibrinolytic Intervention (MELT) were randomized clinical trials (RCTs) undertaken to test the efficacy and safety of a recombinant pro-urokinase drug [ 126 , 127 ], but did not produce any data useful for stroke treatment. Thrombolytics and glycoprotein IIb/IIIa antagonists were combined in two small clinical trials; this approach was helpful in treating atherosclerotic occlusions but less effective for cardioembolism [ 128 , 129 ]. The Interventional Management of Stroke (IMS) III trial tested IVT and IAT together to assess the benefits of combining rapid administration of therapy (IVT) and a superior recanalization methodology for faster relief (IAT) [ 130 ]. The IMS III trial was fruitful with bridging therapy (combination of IVT and IAT) as compared to IVT alone. There was an increase of 69.6% in the recanalization rate using bridging therapy in stroke patients [ 131 , 132 ].

Fibrinogen-depleting agents : Research has found a strong correlation between high fibrinogen levels in stroke patients and poor diagnosis for clinical outcomes. Fibrinogen-depleting agents decrease blood plasma levels of fibrinogen, hence reduce blood thickness and increase blood flow. They also remove the blood clot in the artery and restore blood flow in the affected regions of the brain. However, although some RCTs of defibrinogen therapy identified beneficial effects of fibrinogen-depleting agents in stroke patients, others failed to show positive effects on clinical outcomes after stroke [ 133 ]. Moreover, some studies reported bleeding after treatment with defibrinogen agents. Ancrod is a defibrinogenating agent derived from snake venom that has been studied for its ability to treat ischemic stroke within three hours of onset [ 134 ]. The European Stroke Treatment with Ancrod Trial (ESTAT) concluded that controlled administration of ancrod at 70 mg/dL fibrinogen was efficacious and safe, and achieved lower prevalence of ICH than observed at lower fibrinogen levels [ 135 ].

6.2. Others

Antihypertensive therapy : Hypertension is a risk factor for stroke. There are many reasons for high BP in stroke, including a history of hypertension, acute neuroendocrine stimulation, increased intracranial pressure, stress linked to hospital admission and intermittent painful spells [ 136 ]. Correct treatment of high BP during stroke is uncertain due to contradictory outcomes of clinical studies. Some research shows positive correlations between high BP and stroke-related mortality, hematoma expansion or intracerebral damage, suggesting that high BP should be treated. In other studies, low BP levels led to tissue perfusion and increased lesion size, thereby worsening the clinical outcome [ 137 , 138 ]. The multi-center Acute Candesartan Cilexetil Therapy in Stroke Survivors (ACCESS) Phase II study proved that taking medication (candesartan) for BP during stroke was safe, with no orchestrated cerebrovascular events reported due to hypotension. Similar research has been performed with antihypertensive drugs, such as the Continue Or Stop post Stroke Antihypertensives Collaborative Study (COSSACS) to study the efficacy of antihypertensive therapy in stroke; the Control of Hypertension and Hypotension Immediately Post Stroke (CHHIPS) study, designed to determine the cut-off value for BP during an attack; and the Scandinavian Candesartan Acute Stroke Trial (SCAST), which aimed to measure the effectiveness of the drug candesartan on stroke and cardiovascular disease [ 115 , 139 ]. In the COSSACS study, continuing antihypertensive drugs for a two-week period produced no extra harm as compared to stopping it and might be associated with reduced two-week mortality in patients with ischemic stroke [ 140 ]. The CHHIPS study demonstrated that a relatively moderate reduction in blood pressure lowered the mortality rate [ 141 ], whereas the SCAST study suggested that a careful BP-lowering treatment was associated with a higher risk of poor clinical outcome [ 142 ].

Glucose management : Hyperglycemia (elevated blood glucose) is common in stroke patients, so targeting blood glucose levels is an efficient stroke management strategy. Hyperglycemia > 6.0 mmol/L (108 mg/dL) is observed in most stroke patients; it initiates lipid peroxidation and cell lysis in compromised tissue, leading to stroke complications. An experimental study conducted in a rat model of collagenase-induced ICH found that hyperglycemia worsens edema formation and increases cell death, accelerating the course of ischemic injury. Increased blood glucose level is also associated with progression of infarction, reduced recanalization and poor clinical outcome [ 143 ]. Continuous glucose monitoring systems have been deployed to reduce stroke-related risks in both diabetic and non-diabetic stroke patients [ 144 ].

Antiplatelet therapy : This therapy is used for acute ischemic stroke management and for prevention of stroke incidence. It is also vital in controlling non-cardioembolic ischemic stroke and TIA. Antiplatelet agents like aspirin, clopidogrel and ticagrelor are the most widely used drugs administered to stroke sufferers within the first few days of attack [ 145 ]. Dual antiplatelet therapy, which involves a combination of clopidogrel, prasugrel or ticagrelor with aspirin, has become popular; many studies have tested the efficacy and safety of this dual therapy. It has been claimed that clopidogrel and aspirin combination therapy is most beneficial if introduced within 24 h of stroke and continued for 4–12 weeks [ 146 ].

Stem cell therapy : It offers promising therapeutic opportunities, safety and efficacy to stroke patients. Research on embryonic stem cells, mesenchymal cells and induced pluripotent stem cells has assessed their potential for tissue regeneration, maintenance, migration and proliferation, rewiring of neural circuitry and physical and behavioral rejuvenation [ 147 ]. Recently, a new type of mesenchymal stem cells (MSCs), called multilineage differentiating stress-enduring (Muse) cells, has been found in connective tissue. These cells offer great regenerative capacity and have been tested as a stroke treatment. After intravenous transplantation of Muse cells in a mouse model, they were found to engraft into the damaged host tissue and differentiate to provide functional recovery in the host [ 148 ]. Neovascularization is another mode of action of cell therapies in stroke; studies conducted in vitro and in vivo have shown that transplanted cells promote angiogenesis [ 149 , 150 ]. Furthermore, multiple stroke studies have reported that MSCs stimulate neurogenesis; this was confirmed in human embryonic neural stem cells using BrdU-labelling [ 151 , 152 ]. Stem cell therapy enhances the proliferation of neural stem cells and neuritogenesis [ 153 ]. Careful experimental design and clinical trials of stem cell therapies are likely to usher in a new era of treatment for stroke by promoting neurogenesis, rebuilding neural networks and boosting axonal growth and synaptogenesis.

Neural repair : This is an alternative therapy to neuroprotection. It is used to rejuvenate the tissue when the damage is already done and is therefore not time-bound but is most effective when administered 24 h after stroke attack. Many animal models have been used in attempts to stimulate neurogenesis and initiate the neuronal repair process [ 154 ]. Neural repair utilizes stem cell therapy to initiate repair mechanisms through cell integration into the wound or use of neurotrophic factors to block neuronal growth inhibitors. These cells may be channeled to any injured region to facilitate greater synaptic connectivity. Clinical trials using neural stem cells have proven beneficial in stroke patients. However, trials of myelin-associated glycoprotein, neurite outgrowth inhibitor (NOGO) proteins and chondroitin sulphate proteoglycans have shown these agents to be insufficiently effective; more clinical trials are required to increase treatment efficacy [ 155 ]. Biological intrusions may foster regeneration of newer cells, improve axonal guidance and enhance neural circuitry. Pharmacological and immunological interventions may target receptors to provide signaling cues for regeneration or block inhibitory factors in stroke-affected regions of the brain [ 156 ].

Rehabilitation : Stroke can leave individuals with short- and long-term disabilities. Daily activities like walking and toileting are often affected, and sensorimotor and visual impairment are common. Rehabilitation aims to reinforce the functional independence of people affected by stroke [ 157 ]. It includes working with patients and families to provide supportive services and post-stroke guidance after 48 h of stroke attack in stable patients. Stroke rehabilitation may involve physical, occupational, speech and/or cognitive therapy. It is designed to assist patients to recover problem-solving skills, access social and psychological support, improve their mobility and achieve independent living. Rehabilitation may also include neurobiological tasks designed to lessen the impact of cognitive dysfunction and induce synaptic plasticity, as well as long-term potentiation [ 158 , 159 ]. Neuromodulators play a vital role in triggering expression of specific genes that promote axon regeneration, dendritic spine development, synapse formation and cell replacement therapy. Task-oriented approaches, like arm training and walking, help stroke patients to manage their physical disability, and visual computer-assisted gaming activities have been used to enhance visuomotor neuronal plasticity [ 160 ].

7. Trends in Stroke Research

The incidence of stroke-related emergencies has decreased substantially over recent years due to improved understanding of the pathophysiology of stroke and identification of new drugs designed to treat the multitude of possible targets. Technological advancements like telestroke [ 161 ] and mobile stroke [ 162 ] units have reduced mortality and morbidity. Therefore, stroke management systems should include post-stroke care facilities on top of existing primary care and access to occupational, speech or any physical therapy following hospital discharge. Hospitals should develop standardized policies to handle emergencies in a timely fashion to avoid casualties and prevent secondary stroke [ 163 ]. Recently, the role of physiotherapists has emerged as an important aspect of post-stroke care management. Physiotherapists have initiated clinical trials of stroke recovery processes and rehabilitation therapy sessions. One ongoing study includes a strategy to manage disability by improving mobility using treadmill exercise, electromechanical device therapy and circuit class therapy [ 164 , 165 ]. Stroke Recovery and Rehabilitation Roundtables bring physiotherapists and other experts together to recommend research directions and produce guidance for the post-stroke healthcare system. Optimized delivery of stroke care systems and access to rehabilitation services are the future of healthcare for stroke [ 166 ].

Animal models used in stroke research reflect only a portion of the consequences of the condition in human subjects. Moreover, experiments conducted within a single laboratory are often constrained in terms of their research output. In vivo animal models of stroke should include aged populations to maximize their relevance, but most recent studies involve young and adult animals. Stroke studies should be conducted in both male and female subjects to exclude gender bias, and should take account of other confounders like hypertension, diabetes and obesity. All these issues make stroke research complex and expensive, and imply that it should be carried out collaboratively, across multiple labs. Ideally, an international multicenter platform for clinical trials would be established to increase the validity of research outcomes with respect to efficacy, safety, translational value, dose–response relationships and proof-of-principle. This strategy will help to overcome the current hurdles in transforming laboratory data into therapeutics for stroke.

Advancements in stem cell technologies and genomics have led to regenerative therapy to rebuild neural networks and repair damaged neurons due to ischemic insult [ 167 , 168 ]. The WIP1 gene is a regulator of Wnt signaling and a promising target for drug development. Studies in mice models showed that knockdown of WIP1 downregulates the stroke functional recovery process after injury, and that the presence of this gene regulates neurogenesis through activation of β-Catenin/Wnt signaling [ 169 ]. Similarly, NB-3 (contactin-6) plays a vital role in neuroprotection, as shown by knockdown of NB-3 in mice after stroke attack. NB-3-deficient mice had increased brain damage after MCAo, which also affected neurite outgrowth and neuronal survival rate. NB-3 is believed to have therapeutic benefits for ischemic insult [ 170 ]. Therefore, WIP1 and NB-3 are promising candidates for future drug trials. This is a vast field, and more research must be conducted in the coming years to enable the development of therapeutic drugs.

Numerous natural compounds have proven to be beneficial for stroke prevention and treatment. They can be synthesized at a lower cost than synthetic compounds and offer competitive efficacy and safety. Honokiol is a natural product that showed neuroprotective effects in animal models, and appears to have a role in reducing oxidative stress and inhibiting inflammatory responses [ 171 ]. Gastrodin, a compound extracted from Gastrodia elata , is a promising candidate in stroke treatment. In a mouse model, it improved neurogenesis and activated β-Catenin-dependent Wnt signaling to provide neuroprotection after ischemic insult. It also has antioxidative effects which protects the neural progenitor cells from neuron functional impairment. Gastrodin’s safety has been proved in clinical trials, hence it is an option for stroke management in the coming years [ 172 ].

The Utstein methodology is a process of standardizing and reporting research on out-of-hospital stroke and defining the essential elements of management tools. Its growing popularity led to the establishment of the Global Resuscitation Alliance (GRA), an organization that governs best practices. The primary aim of GRA is to facilitate stroke care from pre-hospital admission to rehabilitation and recovery. It has developed 10 guidelines to ensure smooth transitioning of services during and after attack. It has implemented a stroke registry, public awareness and educational programs, promoted techniques for early stroke recognition by first responders, sought to optimize prehospital and in-hospital stroke care, advocated the use of advanced neuroimaging techniques and promoted a culture of excellence. The Utstein community has developed comprehensive plans to improve early diagnosis and treatment of stroke patients globally [ 173 ].

Future clinical trials should aim not only to determine the efficacy and safety of drugs but to characterize recovery and clinical outcomes. Clinical trials of pharmacological therapies for post-stroke recovery should adhere to the following guidelines [ 174 ]. Patients should be enrolled within two weeks of stroke whenever possible. Studies should include sampling from a multicenter platform and include global scale criteria for data analysis. The underlying mechanism of action of the tested drugs on target molecules should be thoroughly understood. Secondary measurements like day-to-day progress of recovery, length of rehabilitation, treatment endpoint analysis and any other compounding factors should also be recorded. Overall, research on stoke management has advanced rapidly in recent years and is certain to make additional valuable discoveries through the application of new technologies in hypothesis-driven clinical trials.

8. Translational Challenges for the Current Stroke Therapeutic Strategies

Stroke research has seen fundamental advancements over recent years. The improvements in the selection of animal models, imaging techniques and methodological progress have led to immense drug targets and therapeutic interventions. In spite of this, the subsequent clinical trials failed to prove pre-clinical outcomes. Recanalization therapy showed some promising results in the clinical trials but only a small section of stroke patients benefited from this treatment [ 175 ]. Hence, the translational potential of stroke research is still under-investigated.

The key challenges that hinder the smooth transition of pre-clinical research into successful drugs include relevant endpoint selection, confounding diseases models like hypertension and diabetes, modelling age and gender effects in stroke patients, development of medical devices, investigating medical conditions that co-exist during stroke incidence, reproducibility of pre-clinical stroke research data and modelling functional and behavioral outcome [ 176 , 177 , 178 ]. Multiple causality of the stroke occurrence is another problem that is often over-looked. Homogeneity in stroke models to exhibit the broad spectrum of stroke pathophysiology associated with ischemic lesions or cortical or intracerebral damage is critical. Therefore, stroke animal models that target specific causes of stroke should be included. Latent interaction between comorbidities and stroke treatment should be identified to increase the safety and efficacy of the clinical outcome [ 179 ]. Short-term experimental trials often result in failed therapeutic development due to false-negative outcomes in the clinical settings [ 180 ]. Understanding the functional and behavioral output which might mislead true recovery is problematic in clinical trials wherein animal models have greater ability to mask the functional benefits [ 181 ]. This affects the affecting translational capability of the research. Adapting a combined approach to model recovery and rehabilitation is also important for successful transition.

One of the other problems with the clinical trials for stroke is the lack of efficient data management. The impact of large data generated from numerous clinical experiments is over-whelming and there should be a standardized system to manage such data. Moreover, these data should be deposited into a public data repository for easy access.

Industry and academic corroborations in stroke research are critical to improve the translational value [ 182 ]. A consensus between industry and academic interests is vital for successful transition. The industry collaborations are mostly monetary driven and have time constraints which might compromise the pre-clinical study protocol design, appropriate sample sizes and overestimation of treatment effects. IP protection and publication of research data may discord between these groups. A multicenter approach, long-term collaborations, effective project management, use of advanced methodologies and establishment of functional endpoints will probably advance the translational roadblocks in stroke research [ 183 ].

9. Conclusions

Stroke is the second leading cause of death and contributor to disability worldwide and has significant economic costs. Thus, more effective therapeutic interventions and improved post-stroke management are global health priorities. The last 25 years of stroke research has brought considerable progress with respect to animal experimental models, therapeutic drugs, clinical trials and post-stroke rehabilitation studies, but large gaps of knowledge about stroke treatment remain. Despite our increased understanding of stroke pathophysiology and the large number of studies targeting multiple pathways causing stroke, the inability to translate research into clinical settings has significantly hampered advances in stroke research. Most research has focused on restoring blood flow to the brain and minimizing neuronal deficits after ischemic insult. The major challenges for stroke investigators are to characterize the key mechanisms underlying therapies, generate reproducible data, perform multicenter pre-clinical trials and increase the translational value of their data before proceeding to clinical studies.

Author Contributions

Conceptualization, D.K.; writing—original draft preparation, D.K.; writing—review and editing, Z.X.; funding acquisition, Z.X. All authors have read and agreed to the published version of the manuscript.

This research and The APC was funded by Apex Biotech Research.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Care Process of the Stroke Patients Case Study

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Many health experts have discovered that stroke is the main reason of deaths in the world, which may also cause disability in case a person survives. Due to the brain damage accompanied by the stroke, the victim needs long-term personal care to increase his/her chances to live a long life (Evashwick, 2005).

Although stroke victims rarely recover, there are some cases when it takes at least two years to get over it. Stroke completely disables a victim as the one is unable to do a thing, and therefore, the patient is useless for a long period or the entire lifetime. During this period, the person will need intensive personal care and attention. Therefore, the only people able to help the stroke victim are the family members or the guardians.

The most important step in handling a stroke survivor is to prepare him or her psychologically for any eventual outcome of the disability. Medical experts associate stroke with frequent back pains. It is important for the patient to understand all the possible outcomes of the stroke (Bogousslavsky, 2002).

The family members should closely monitor the patient since isolating a patient on the basis of his/her disability worsens the state of health and does not contribute to the improving. Stroke patient is likely to recover faster when he or she feels appreciated in the society than becomes alienated from the world.

To improve the standards of care of the patient, the family should consider buying some important equipment for use by the patient so that he or she can at least perform some tasks on his/her own. Such equipments include the wheelchair, handheld urinal and bedside commode.

The wheelchairs are very essential as they give a person an opportunity to move anywhere within their ability. The handheld urinal and the bedside commode are very important for individual wellbeing as they help an individual to answer the call of nature when no one is within to help. Though these equipments are very expensive, they are very resourceful in the long run in assisting the stroke patient within the family (Bogousslavsky, 2002).

Long-term care will aid the stroke patients because they are no longer able to do any task on their own. There are several services that the stroke patient will need in the long run. These are nursing, medical, community, social and custodial services. Moreover, these services can also be provided at nursing homes or personal homes. Family members must note that stroke patients who are not well attended to are prone to deteriorating health eventually shortening their life span.

It is also important to note that a person providing a personal care to stroke patients should know that the stroke survivors cannot express themselves freely regarding their urgent needs. For example, bathing, grooming and dressing require a close family member to assist a patient in most occasions (Evashwick, 2005). Moreover, helping the patient use the toilet and eat are the most essential activities that promote the stroke victims’ health standards and wellbeing.

In some cases, it is possible for a family to hire a specialized caregiver to attend to the patient when the family is not able to attend to a person. Stroke survivors need a specialized attention all the time which will also call for more resources to be used.

The family may ask for a help from a professional nurse or take the patient to a nursing home for more specialized care. Moreover, specialized medication is also needed to help the patient to get over, which calls for taking concerted actions to ensure the stroke victim receives the best health care (Evashwick, 2005).

Bogousslavsky, J. (2002). Long-term effects of stroke . New York: M. Dekker.

Evashwick, C. (2005). The continuum of long-term care . New York: Thomson/Delmar Learning.

• A Hospital Emergency Room
• Communication Modality Used For Marketing in Health Care
• The Effects of Ergonomic Wheelchairs on Permanently Chair Bound People
• Bedside Shift Report in the Nursing
• Sepsis Case: Symptoms and Resuscitation
• Healthcare Innovation: Ground Source Heating & Cooling Equipment
• The Concept of Medical Terminology
• Medical terminology errors
• Medical terminologies for dummies
• Medical Professionals Exam
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2018, December 19). Care Process of the Stroke Patients. https://ivypanda.com/essays/care-of-the-stroke-patients/

"Care Process of the Stroke Patients." IvyPanda , 19 Dec. 2018, ivypanda.com/essays/care-of-the-stroke-patients/.

IvyPanda . (2018) 'Care Process of the Stroke Patients'. 19 December.

IvyPanda . 2018. "Care Process of the Stroke Patients." December 19, 2018. https://ivypanda.com/essays/care-of-the-stroke-patients/.

1. IvyPanda . "Care Process of the Stroke Patients." December 19, 2018. https://ivypanda.com/essays/care-of-the-stroke-patients/.

Bibliography

IvyPanda . "Care Process of the Stroke Patients." December 19, 2018. https://ivypanda.com/essays/care-of-the-stroke-patients/.

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 7:  10 Real Cases on Transient Ischemic Attack and Stroke: Diagnosis, Management, and Follow-Up

Jeirym Miranda; Fareeha S. Alavi; Muhammad Saad

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Case review, case discussion, clinical symptoms.

• Radiologic Findings
• Full Chapter
• Supplementary Content

Case 1: Management of Acute Thrombotic Cerebrovascular Accident Post Recombinant Tissue Plasminogen Activator Therapy

A 59-year-old Hispanic man presented with right upper and lower extremity weakness, associated with facial drop and slurred speech starting 2 hours before the presentation. He denied visual disturbance, headache, chest pain, palpitations, dyspnea, dysphagia, fever, dizziness, loss of consciousness, bowel or urinary incontinence, or trauma. His medical history was significant for uncontrolled type 2 diabetes mellitus, hypertension, hyperlipidemia, and benign prostatic hypertrophy. Social history included cigarette smoking (1 pack per day for 20 years) and alcohol intake of 3 to 4 beers daily. Family history was not significant, and he did not remember his medications. In the emergency department, his vital signs were stable. His physical examination was remarkable for right-sided facial droop, dysarthria, and right-sided hemiplegia. The rest of the examination findings were insignificant. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. The neurology team was consulted, and intravenous recombinant tissue plasminogen activator (t-PA) was administered along with high-intensity statin therapy. The patient was admitted to the intensive care unit where his hemodynamics were monitored for 24 hours and later transferred to the telemetry unit. MRI of the head revealed an acute 1.7-cm infarct of the left periventricular white matter and posterior left basal ganglia. How would you manage this case?

This case scenario presents a patient with acute ischemic cerebrovascular accident (CVA) requiring intravenous t-PA. Diagnosis was based on clinical neurologic symptoms and an NIHSS score of 7 and was later confirmed by neuroimaging. He had multiple comorbidities, including hypertension, diabetes, dyslipidemia, and smoking history, which put him at a higher risk for developing cardiovascular disease. Because his symptoms started within 4.5 hours of presentation, he was deemed to be a candidate for thrombolytics. The eligibility time line is estimated either by self-report or last witness of baseline status.

Ischemic strokes are caused by an obstruction of a blood vessel, which irrigates the brain mainly secondary to the development of atherosclerotic changes, leading to cerebral thrombosis and embolism. Diagnosis is made based on presenting symptoms and CT/MRI of the head, and the treatment is focused on cerebral reperfusion based on eligibility criteria and timing of presentation.

Symptoms include alteration of sensorium, numbness, decreased motor strength, facial drop, dysarthria, ataxia, visual disturbance, dizziness, and headache.

Get Free Access Through Your Institution

Pop-up div successfully displayed.

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

Stroke Case Study

Chapter 1 Introduction Title: EFFECT OF INTENSIVE STRENGTH TRAINING EXERCISES ON BALANCE AND MOBILITY IN POST STROKE HEMIPLEGICS – A PROBE STUDY. 1. Introduction Stroke is a leading neurological disorder and causes long-term disability worldwide. The definition of stroke was recently updated by 2009 task committee endorsed by American heart and stroke associations as follows. Stroke refers to a CNS infarction. “A CNS infarction is brain , spinal cord, or retinal cell death attributable to ischemia, based on (a) Pathological imaging, or other objective evidence of cerebral, spinal cord or retinal focal ischemic injury in a defined vascular distribution; …show more content…

The CVA can be a hemorrhage or thrombus and the severity of the lesion determines the loss of function. In extensive disease, neighboring neurons may also be affected. Following a stroke, the oxygen supply to brain cells is blocked and cells start to die within minutes. This will be reflected by symptoms like sudden weakness, paralysis or numbness of the face, arms, or legs, difficulty in communication, loss of consciousness etc. The loss of function in stroke is dependent on the number of neurons involved and how long the blood flow to the brain has been interrupted. Early diagnosis, underlying cause and time taken for the commencement of treatment play the main role in determining whether the deficit is stable, progressive, or completely …show more content…

Ischemic stroke is more common type of stroke, occurs around 80% of all strokes (Feigin et al., 2003), of which 60% are involved with large-artery ischemia. Following ischemia there is a local reduction in oxygen supply or nutrients, results in failure of energy production such as adenine triphosphate (ATP). This harmfully influences the tissue cell survival, and leads to cellular damage and death. The amount of cellular injury depends upon extend of illness, severity, and area involved (Deb P,

Randy Bolton's Case Study

A stroke is the sudden death of brain cells due to the lack of oxygen, caused by blockage of blood flow or a rupture of an artery to the brain. Sudden loss of speech, weakness, or in Bolton’s case, paralysis of one side of the body can be the symptoms of a stroke. A suspected stroke can be confirmed by scanning the brain with special x-ray tests, such as CAT scans. The death rate and level of disability resulting from strokes can be dramatically reduced by immediate and appropriate medical care.

Explain The Makeup And Function Of The Blood Brain Barrier

The Blood Brain Barrier or (BBB), is a protective

Amyotrophic Lateral Sclerosis (ALS)

Imagine being a competitive athlete that can do almost anything and in a matter of seconds never being able to hug love ones or do the simple everyday tasks many take for granted. That’s how life is when a person is diagnosed with Amyotrophic Lateral Sclerosis (ALS) it’s a fatal disease that causes a person to lose complete control of their body and constantly need assistance. Having ALS also means having to watch the body deteriorate when the mind is perfectly aware of its own demise. Being diagnosed with Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease caused by multiple severe concussions to the head.

How Did Charlie Gordon Get Iq Surgery

A unneeded brain surgery could cause someone to die or go brain dead. Also as Charlie’s intelligence wore off, he got sick, staying in bed for weeks not eating. He went into emotional instability. Finally Charlie could die like Algernon died. Algernon died after his surgery wore off due to smoothing of the cerebral convolutions.

Outline For Als Research Paper Outline

When the motor neurons start to die, the ability of the brain to start and control muscle movement is eventually stopped. With muscle action

Second Impact Syndrome Research Paper

The condition is often fatal, and almost everyone who is not killed is severely disabled. The cause of SIS is uncertain,but it is thought that the brain's arterioles lose their ability to regulate

Cerebral Edema Research Paper

If untreated cerebral edema can cause death. When treated it may still have lingering effects on the body such as: loss of vision, cerebral atrophy with cognitive decline, and altered mental

Outline The Factors That Can Affect An Individual's Views On Death And Dying Essay

- If an individual has poor cognition, suffering from a stroke and in general has a lack of mental capacity this will affect them on how they understand death and

Traumatic Brain Injury

Symptoms may include dizziness, nausea and confusion. Although the loss of consciousness is possible, it is usually brief. The diagnosis of mild brain injury such as a concussion, usually made based on symptoms and a CT scan, which is used to rule out more serious injuries. The treatment is often not necessary.

Symptoms And Definition Of Aneurysm

Brain Aneurysm Four major blood vessel supply blood to the brain. They join together at the circle of willis at the base of the brain. Smaller arteries leave the circle and branch out to supply brain cells with oxygen and nutrients. Artery junction points may become weak causing a ballooning of the blood vessel wall to potentially form a small sac or aneurysm. Cerebral aneurysms are common but most are asymptomatic and are found incidentally at autopsy.

Concussions And Head Trauma

What is it like to have ALS or a CTE? Either a progressive neurological disease that attacks your motor skills or one that attacks the cognitive parts of the brain. Each one has its own particular attack strategy. On one hand the body is rendered completely motionless while being completely conscious of the outside environment. On the other, the body stays unharmed while it slowly loses the mind, both are equally devastating.

Stroke Prognosis Essay

False 7. According to one small study mentioned in the article, the volume of ischemic tissue can be determined by MRI within how many hours of stroke onset? a. 12 hours b. 24 hours c. 36 hours d. 48 hours 8. Acute occlusion of the cervical internal carotid artery, basilar artery, or a large intracranial artery is associated with a(n) ______________ risk of poor outcome.

Pediatric Stroke

Stroke may be somewhat unlikely to happen in children but when it does happen it has a significant impact because it can cause morbidity and mortality. Children’s strokes can present differently than adult. Also according to the “Pediatric Stroke: A Review”, “The reported incidence rate of both ischemic and hemorrhagic pediatric stroke ranges from 1.2 to 13 cases per 100,000 children under 18 years of age”(Tsze & Valente 1). Nevertheless, Pediatric CVA is more familiar than we can imagine, because of the misdiagnoses. In one report, it is said that 19 out of 45 children with a stroke did not obtain the accurate diagnosis until 15 hours to 3 months after initial presentation.

Transient Ischemic Attack Essay

A Transient Ischemic Attack, also known as a mini stroke, is an acute illness where blood flow to a certain part of the brain gets blocked which most of the time is caused by a blood clot (Webmd n.d.). After a couple minutes the clot dissolves, blood flow continues again and symptoms disappear. It is called a mini stroke because all the signs and symptoms are the same as a stroke, but the symptoms last a shorter period of time and there is no permanent damage done to the cells. According to the website mayoclinic.org, About 1 in 3 people who have a transient ischemic attack will eventually have a stroke, with half occurring within a year after the transient ischemic attack (Mayo Clinic Staff 2014). Overall, even though it is considered a mini stroke and the symptoms last shorter time, it is still a serious condition and need medical attention immediately.

Still Alice Movie Analysis

This study would be useful in studying about early onset of AD, as it informs on the direction of diagnosing early-onset

More about Stroke Case Study

Related topics.

• Health care
• Myocardial infarction

YOUR FINAL GRADE - GUARANTEED UK Essay Experts

Disclaimer: This essay is provided as an example of work produced by students studying towards a nursing degree, it is not illustrative of the work produced by our in-house experts. Click here for sample essays written by our professional writers.

Please refer to an authoritative source if you require up-to-date information on any health or medical issue.

Stroke Case Study | Pathophysiology and Care Delivery Plan

Reference this

Get Help With Your Essay

If you need assistance with writing your essay, our professional essay writing service is here to help! Find out more about our Essay Writing Service

Cite This Work

To export a reference to this article please select a referencing stye below:

Related Services

Essay Writing Service

• Dissertation Writing Service

• Assignment Writing Service

DMCA / Removal Request

If you are the original writer of this essay and no longer wish to have your work published on UKEssays.com then please:

Our academic writing and marking services can help you!

• Find out more about our Essay Writing Service
• Undergraduate 2:2
• 7 day delivery
• Marking Service
• Samples of our Service
• Full Service Portfolio

Related Lectures

Study for free with our range of university lecture notes!

• Nursing Lectures
• All Available Lectures

Freelance Writing Jobs

Looking for a flexible role? Do you have a 2:1 degree or higher?

Study Resources

Free resources to assist you with your university studies!

• More Nursing Resources at NursingAnswers.net
• Reflective Models at NursingAnswers.net
• How to Write an Essay
• Essay Buyers Guide
• Referencing Tools
• Essay Writing Guides
• Masters Writing Guides

Stroke Case Study Essay

Introduction A stroke occurs when there is a sudden decrease in blood flow to a localized area in the brain (Trakalo, 2015, p.1234). This can occur in different ways such as a thrombus, an embolus, a stenosis, or a hemorrhage - all of which can cause devastating neurological effects depending on the extent of ischemia and necrosis resulting from the decreased oxygen carried by the blood. According to The Stroke Association of the UK, an individual that smokes is 3 times more susceptible to suffering from a stroke than that of a person who does not smoke. With that being said, the more cigarette smoke inhaled per day places an individual at an even higher risk (“ Smoking and the risk of stroke,” 2012, para. 2). National Institute of Neurological …show more content…

The client must know that quitting betters and lengthens a person’s life by a number of years. The following material corresponds with each objective listed above. 1. Teach the client how smoking directly compares with the added risk of having a stroke. Smokers should know that smoking cigarettes could cause a stroke to happen in many ways. One of these ways is that chemicals in cigarette smoke damage the cells in a person’s body. Also, smoking can raise the bad cholesterol (which is fat) in the blood. When there is more fat in the blood, it causes arteries (vessels that carry blood to the heart) to become blocked. If arteries are blocked, then the oxygen that is needed cannot get through to the brain. Just like any other organ in the body, oxygen is important for the brain to work. Lastly, smoking increases platelets in the blood. Platelets cause the blood to become thicker and clot. A clot can block a blood vessel anywhere in the body, and if the clot moves to the brain, then it will block the vessel there causing oxygen to not be able to pass through (“Smoking and the risk of stroke,” 2012, “How does smoking cause stroke”, para.

Hcs 451 Letter To The Editor

Justine Morgan (2014) divulge that Nicotine which is contained in e-cigarettes is an addictive drug that affects the brain, nervous system, and the heart. It also increases blood pressure, causes abnormal heart rate and blood clotting, a leading factor to stroke. Nicotine though may not be harmful if taken within the prescribed limit but narrow the blood vessels (Amanda & Woerner, 2014) and this could lead to stroke and other health issues.

Health Promotion Essay

The harmful effects of smoking are well known. Smoking increases the chances of chronic disease’s for example Lung Cancer, with 90% of these cases being caused by smoking (Cancer Research UK 2009). Responsible for 5200 lives per year, the huge financial burden on the National

COPD Research Paper

According to a recent research (http://www.thehealthsite.com/news/passive-smoking-just-as-harmful-ups-stroke-risk-in-non-smokers-i715/), passive smoking increased the risk of stroke by 30/% in non-smoking

stroke Essay

• 1 Works Cited

Cerebral vascular accident or a stroke is the destruction of brain substance, resulting from thrombosis, intracranial hemorrhage, or embolism, which causes vascular insufficiency. In addition, it is an area of the brain denied blood and oxygen that is required and damage is done to a part of the cells. The effect of the patient depends upon where the damage occurs and the severity of the stroke.

Transient Ischemic Attack

Tobacco Use ¡V Cigarette smoking is a major, preventable risk factor for stroke. Smoking contributes to plaques in your arteries. Also, nicotine raises blood pressure.

Essay on Stroke

A cerebrovascular accident more commonly known as a stroke or brain attack is the term used to describe the sudden death of brain cells in a localized area due to inadequate blood flow. In order to woke the brain needs a constant supply of oxygen and nutrients. This supply is carried to the brain

Life After Stroke Essay

Stroke affects everybody differently, and it is difficult to say how much of a recovery is possible. Many stroke survivors experience the most dramatic recovery during their stay in hospital in the weeks after their stroke.

Essay about A Stroke

A stroke is a type of cardiovascular disease that affects the cerebral arteries, those blood vessels that carry blood to the brain. A stroke occurs when one of those blood vessels in the brain is obstructed or ruptures flooding the brain with blood. Depriving blood and oxygen to the brain results in those immediate cells death, causing the brain not to function properly. Once parts of the brain stop functioning, it can directly affect the areas of the body controlled (1).

Stroke Risk Factors

Acheson 1998; Marmot 2010; Scientific Committee on Tobacco and Health (1998), Smith (2013). The goal is to review the evidence-based recommendations for the stroke risk factors. A modification in a person’ current and future health status can be credited to antecedent health care. The overall long-term impact of health interventions are both on populations as a whole and on individuals in particular (Wolfe et al., 1996). Cerebrovascular diseases can be prevented by addressing known, modifiable risk factors. It is important to identify risk factors for stroke and sources in order to take steps towards preventing stroke and provides concrete actions to reduce the burden of stroke within a population (Mohr et al.,

Explain Why There Should Be A Fine For Smoking In Public

Lung disease, COPD, Heart disease, and many cancers are just a few examples of the effects smoking has on a person. COPD is one of the most major diseases smoking can cause. The effects of COPD can range anywhere from long-term disability to an early death. A loss of sense of smell and taste, decaying teeth, eye cataracts, and increased risk of stroke are other terrible things that can occur from smoking. A smoker may not think of these dangerous possibilities while smoking, but the danger of smoking will never cease until awareness of its harm is

Research Paper on Tobacco

Cigarette smokers are two to four times more likely to develop coronary heart disease than non-smokers, and tobacco use doubles risk for stroke. It also causes reduced circulation by narrowing the blood vessels, and it causes premature wrinkles because it constricts the oxygen and warmth from all parts of the body so the skin ages faster.

The Effects of Smoking Tobacco Essay

• 9 Works Cited

Regardless of consumer belief, smoking dramatically increases the chances of contracting many diseases - such as heart disease or high blood pressure. Although not every user experiences these diseases, it is well known that smoking can decrease one’s life time dramatically. The information given states, “It’s virtually impossible to escape the effects of tobacco” (Jordan). This stated, Jordan expresses that essentially if you use tobacco, there is a fairly high chance that one will damage his/her body in some way. Furthermore, there are many more diseases that can be contracted and the ones stated are only the most common. Continuing, the author explains the affects of smoking, “Expose to specific elements of secondhand smoke causes blood clot more easily and damages arterial lining” (Jordan). As stated, certain components in tobacco increase the chances of high blood pressure and blood clots to form in the body. Concluding, respiratory problems in young children can occur through second hand smoking, these include asthma. Children that asthma effect increases from smoke, “Asthma turns out to be about twice as common in children exposed to high levels of second hand smoke” (Secondhand Smoke: Is it a Hazard). Not only does tobacco smoke increase other diseases, it also increases the severity of diseases already contracted as shown in the previous quote. To conclude, tobacco smoke

Smoking and the Effects on the Heart Essay

The Surgeon General has called it "the leading preventable cause of disease and deaths in the United States." Smoking is among the top preventable risk factors of heart disease amongst many other health problems. Coronary heart disease and strokes are the primary types of cardiovascular disease caused by smoking. They rank as the first and third leading causes of death in the United States. More than 61 million Americans suffer from some form of cardiovascular disease. Smoking increases your risk for high blood pressure, coronary heart disease, stroke, congestive heart failure, and aneurysms to name a few. More than 2,600 Americans die every day from cardiovascular diseases.

Essay on Addictions to Smoking and Alcohol

Smoking increases the risk of suffering from heart diseases, stroke, other lung diseases and other respiratory illnesses. The body develops horrific reactions to the daily onslaught of smoking. It damages the blood vessels in the legs and arms for example, which lead to restricted circulation and even amputation of the limbs. Also, a smoker addict will eventually start getting eye irritations (which leads to blindness), foul smelling hair, hair loss and even start developing a loss of smell. All of these reactions are due to the dangerous chemicals cigarettes contain.

Cigarette Smoking Essay

• 2 Works Cited

Another cardiovascular malfunction that cigarette smoking may cause are strokes. A stroke is damage to the brain caused by leakage from a ruptured blood vessel or an interruption in blood supply. Nicotine and carbon monoxide in cigarette smoke affect the adhesives of blood platelets, the main clotting factor in blood. This can cause blood vessels to harden and form blood clots that can flow to the brain, a major cause of strokes. Nicotine can also cause the blood vessels to constrict. When a smokers arteries become too constricted,

Related Topics

• Tobacco smoking
• Smoking cessation

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Global health
• BMJ Journals

You are here

• Volume 13, Issue 8
• Clinical course of a 66-year-old man with an acute ischaemic stroke in the setting of a COVID-19 infection
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0002-7441-6952 Saajan Basi 1 , 2 ,
• Mohammad Hamdan 1 and
• Shuja Punekar 1
• 1 Department of Stroke and Acute Medicine , King's Mill Hospital , Sutton-in-Ashfield , UK
• 2 Department of Acute Medicine , University Hospitals of Derby and Burton , Derby , UK
• Correspondence to Dr Saajan Basi; saajan.basi{at}nhs.net

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.

• respiratory medicine
• infectious diseases
• global health

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

Statistics from Altmetric.com

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.

• Download figure
• Open in new tab
• Download powerpoint

A graph showing the number of patients with COVID-19 in the hospital and in the community over time.

Case presentation

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.

Investigations

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.

• View inline

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.

Outcome and follow-up

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

Learning points

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.

• Cannine M , et al
• Wunderink RG
• van Doremalen N ,
• Bushmaker T ,
• Morris DH , et al
• Wang X-G , et al
• Grasselli G ,
• Pesenti A ,
• Wang M , et al
• American Stroke Assocation, 2020
• Zhang Y-H ,
• Zhang Y-huan ,
• Dong X-F , et al
• Li X , et al
• Hu C , et al
• Zhang S , et al
• Jiang B , et al
• Xu J , et al
• British Association of Stroke Physicians

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.

Read the full text or download the PDF:

24/7 writing help on your phone

To install StudyMoose App tap and then “Add to Home Screen”

Stroke - Case Study

Save to my list

Remove from my list

Stroke - Case Study. (2016, Sep 28). Retrieved from https://studymoose.com/stroke-case-study-essay

"Stroke - Case Study." StudyMoose , 28 Sep 2016, https://studymoose.com/stroke-case-study-essay

StudyMoose. (2016). Stroke - Case Study . [Online]. Available at: https://studymoose.com/stroke-case-study-essay [Accessed: 30 Aug. 2024]

"Stroke - Case Study." StudyMoose, Sep 28, 2016. Accessed August 30, 2024. https://studymoose.com/stroke-case-study-essay

"Stroke - Case Study," StudyMoose , 28-Sep-2016. [Online]. Available: https://studymoose.com/stroke-case-study-essay. [Accessed: 30-Aug-2024]

StudyMoose. (2016). Stroke - Case Study . [Online]. Available at: https://studymoose.com/stroke-case-study-essay [Accessed: 30-Aug-2024]

• Stroke and It’s Causes Pages: 6 (1657 words)
• About Jill Bolte Taylor’s “My Stroke of Insight” Pages: 3 (807 words)
• Pathophysiology Of Stroke And Aspects Of Nursing Care Pages: 7 (1889 words)
• Nursing Care for Ischaemic Stroke Patient: Mr. Greens Pages: 4 (1094 words)
• Unveiling the Truman Doctrine: A Bold Stroke in Cold War History Pages: 2 (483 words)
• A Case Study of the H.B. Fuller Case on Honduras Pages: 13 (3793 words)
• A Case Study Of The Miranda V. Arizona Case: a Book Review Of Swanson, Territo And Taylor Pages: 3 (848 words)
• The online study Bible Study Tools defines adoption as the acceptance of Pages: 9 (2663 words)
• A Case Study of Domino’s Pizza’s Crisis Communication Strategies Pages: 11 (3055 words)
• A CASE STUDY - STRATEGY AT H&R BLOCK, INC. Pages: 33 (9732 words)

👋 Hi! I’m your smart assistant Amy!

Don’t know where to start? Type your requirements and I’ll connect you to an academic expert within 3 minutes.

Stroke Case Study Stroke

Show More Stroke Case Study 1. The man has had an ischaemic stroke, identify the biological changes that would have occurred in his brain during the process. Arnold’s ischaemic stroke would be initiated when a lack of blood supply (ischaemia) is prevented from reaching the brain (NHS, 2016). The lack of oxygen causes the neurons within the brain to start a chain reaction, in the form of an ischaemic cascade. This begins seconds after the onset of ischaemia. The ischaemic cascade is a biological reaction, it starts when there is a lack of oxygen and glucose this prevents the cells from creating adenosine tri-phosphate (ATP); this is the energy supply for cells. The organelle mitochondria, produces ATP, which regulates the chemicals within the cell, …show more content… This symptom could determine that the left hemisphere of the frontal lobe has been affected. As the paralysis only affects one side this indicates hemiparesis (Verywell, 2016), as Arnold’s right arm is unaffected. Arnold’s hemiparesis could also support the theory that the stroke occurred in the frontal lobe (Brain injury-explanation, 2016). Arnold’s symptoms of speech difficulties, hemiparesis and loss of sensation indicate that the area of the broca’s region has been affected. 3. Identify the signs and symptoms of a stroke: The signs of a stroke can be recognised by the acronym FAST: Face: Has the face drooped, no longer mirrors facial movements Arms: Unable to lift both arms, due to numbness or paralysis Speech: Is the speech slurred or incoherent Time: Is vital in suspected stroke, immediate medical attention is required (NHS, 2016) Confusion, severe headaches and dizziness could also be symptoms of a stroke (Stroke|brain & spine, 2016). The faster help is obtained, prevents further damage to the brain, as 32000 neurons die every second (Consumer Healthday, 2016). 4. Discuss the likely treatment options and prognosis for the …show more content… (emedicine, 2016). Overall the prognosis after an ischaemic stroke could be calculated by using the National Institutes of Health stroke scale. Arnold’s prognosis could be calculated here and if he scores less than 10 on the scale, the prognosis over the next year becomes more favourable (news medical net, 2016). Different factors to take into consideration towards Arnold’s prognosis would be his age, previous history of high-blood pressure. As high blood pressure was a factor of 54% of stroke sufferers across the United Kingdom (Stroke, 2016). Arnold is now at risk of having another stroke, as one in four people who have had a stroke are now at risk from another stroke (Stroke org, 2016). 5. Emotional and behavioural changes can occur following a stroke. Using evidence to support, discuss the potential difficulties that these could have in relation to the man’s day to day

Related Documents

G. b.: a case study.

Personal Information G.B. is a 74-year-old male that endured a left hemisphere cerebrovascular accident (CVA) after his involvement in a vehicular accident on his way to visit his daughter. The CVA resulted in a diagnosis of severe Broca’s aphasia. It has been seven months since the stroke occurred and G.B.’s symptoms have evolved. Medical Background G.B. suffered a stroke caused by damage to the left inferior frontal gyrus. The location of the damage resulted in the right hemiplegia which G.B. presents with.…

Aaron Green Nursing Case Study

As per your request, I have reviewed Aaron Green’s medical care rendered from 4/29/15 to 6/10/15 to determine if Mr. Green would have been a candidate for drugs to combat his stroke if he had received medical care sooner. Signs and symptoms of stroke include sudden numbness or weakness in the face, arm, or leg, especially on one side of the body, confusion, trouble speaking, or difficulty understanding speech, trouble seeing in one or both eyes, trouble walking, dizziness, loss of balance, or lack of coordination, or a sudden severe headache with no known cause. The risk factors for stroke include hypertension, cigarette smoking, heart disease, diabetes, cholesterol imbalance, inactivity and obesity. During a stroke every minute counts, requiring fast treatment to reduce the…

Cerebrovascular Accident Research Paper

Cerebrovascular accident (stroke) death occurs when you have a sudden death in brain cells due to the lack oxygen. An artery of the brain is ruptured or the brain is impaired by a blockage when there is a lack of oxygen. Cerebrovascular accident (stroke) is associated with and also the medical term for having a stroke. There are certain important signs that you should pay attention and watch out for when associated with cerebrovascular accident (stroke) signs and symptoms of cerebrovascular accident are numbness and weakness in the face, arm, leg or usually one side of the body. Feeling numbness on one side of your body is probably one of the biggest signs associated with the cerebrovascular accident disease.…

Capstone Research Paper

A stroke is caused when there is an interruption of blood flow to the brain. This interruption of blood flow deprives the brain of the oxygen and glucose that it needs to function (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011). It is essential to get a stroke patient the proper…

Short Story Of A Stroke Survivor

Stroke Survivor On November 30th, 2015 my father, Orlin Ostby suffered a massive stroke. He was found in his bed by our neighbor, unable to move or speak. Our neighbor called 911 and an ambulance rushed my dad to the hospital, where it was determined that he had suffered from a stroke and was lucky to be alive. The stroke effected the right side of his brain causing weakness in his left arm, the inability to move his left leg and slurred speech.…

Case Study: Nursing Management Of A Patient With Stroke

Case Study: Nursing Management of a patient with Stroke Introduction This essay will consider the case of John, a stroke patient. Biological as well as psycho-social aspects of his condition will be presented and the impact on his health condition; He is an active smoker and occasionally drinking over the weekend (2 bottles of wine), recently retired and used to work as a lorry driver for Ford. He lives alone, independently.…

Conflict Theory Of Stroke

Stroke: The Sociology Behind It According to John Hopkins Medicine (n.d.), Hippocrates, the father of medicine, discovered stroke about 2400+ years ago, but at the time, the Greek referred to stroke as apoplexy which meant “struck down by violence”. Sometimes referred to as a brain attack, stroke is a cerebrovascular disease that damages portions of the brain because of the tremendous loss of blood vessels individuals experience. Some sources label stroke as a chronic disease and others label it as an acute disease. Conclusively, as implied, this disease has tormented many individuals of many ages for a long period of time, and this paper addresses the sociological rather than the medical aspect of a stroke.…

Physical Health Assessment Summary

• 5 Works Cited

Additionally, neurologically, R.M. had suffered from two strokes in 2013 one on the right and left hemisphere of the brain. Porth describes a stroke as an "acute focal neurologic deficit from a vascular disorder that injures brain tissue (Porth, 2009). " The strokes were believed to…

Traumatic Brain Injury (TBI)

"Brain injury referred to as traumatic brain injury (TBI), is defined as an alteration in brain function or other evidence of brain pathology caused by an external force. Acquired brain injury (ABI), is defined as an injury to the brain which is not hereditary, congenital, degenerative or induced by birth trauma. Today, any traumatic brain injury is an acquired brain injury, defined as any acquired disruption of brain function. " Causes of TBI are trauma (open, closed, crushed, penetration: gunshot or knife wound, severe shaking or from contact sports), stroke (bleeding or a blocked artery), Anoxia (absence of oxygen), severe infection (meningitis, encephalitis), tumor (compression on the tissues causing malfunction), surgery (the actual cutting into a brain to remove a tumor or piece of the brain).…

Massage Therapy

The leading cause of long term disability in the United States is stroke, and one American dies from stroke about every four minutes. Stroke by definition is the sudden death of brain cells due to lack of oxygen. The main types of stoke are hemorrhagic, ischemic, and a transient ischemic attack. Hemorrhagic stroke is broken in to two types, and the most common is the intracerebral hemorrhage, when an artery in the brain bursts flooding the brain with blood. The second and less common subarachnoid hemorrhage, when bleeding occurs in the area between the brain and the thin tissue that covers it.…

Hemorrhagic Stroke Essay

There are two main kinds of strokes: ischemic stroke and hemorrhagic stroke. Ischemic stroke is the main kind of strokes and it takes up to 80% of all strokes. It is caused by a blockage of blood flow of part of the brain and therefore, results in death of parts of brain tissue. The other kind of stroke is hemorrhagic stroke, which is caused by bleeding.…

Anabolic Strokes

Strokes are the third leading cause of death in the U.S., accounting for 140,000 deaths each year in the U.S., and over 5 million worldwide. They are caused by blood clots or vessel ruptures in the brain, causing the death of the surrounding brain cells. There are two types of strokes: ischemic strokes and hemorrhagic strokes. Ischemic strokes are caused by blot clots that form in the brain, called thrombotic strokes, or form in other body parts and travel to the brain, called embolic strokes. This type of stroke accounts for 87% of all stroke cases.…

My Beautiful Broken Brain Analysis

The movie that we viewed in class was My Beautiful Broken Brain. This film was mainly about Lotje Sodderland, and how she had experienced an intracerebral brain hemorrhage or a stroke. The film allows us to see what it was like along the road of recovery with her and all the struggles she underwent. A stroke, also known as cerebrovascular accident, is one of the most frequent cause of brain damage (Gilliam & Marquardt, 2016). There are multiple types of strokes (Gilliam & Marquardt, 2016).…

Case Study Of A Biopsychosocial Model Stroke

A Biopsychosocial Model: Stroke This essay explores how stroke can be caused by referring to the biopsychosocial model and its strength and weakness is evaluated in terms to health. It also address how risk of getting stroke can be significantly decreased by changing our lifestyle behaviour. The links between broader aspects of health with biological or psychological aspect of health is also explored. The biopsychosocial (BPS) model explains that cause of an illness is due to complex interaction between biological, social and psychological factor (Nursing theories, 2013).…

Stroke-Personal Narrative

8 Months into my sophomore year of highschool, I faced the most arduous obstacle I had ever experienced. This imposing setback affected me in more ways that I had thought possible and later on becoming a truly significant turning point in my life. Summer was just around the corner, I was looking forward to making so many plans to fill up those 3 months that felt boundless at the time. Little did I know, late Sunday night my plans would be made for me. A summer full of successive doctors appointments.…

Related Topics

Ready to get started.

• Create Flashcards
• Mobile apps
•   Facebook
•   Twitter
• Cookie Settings

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

A qualitative study of stressors faced by older stroke patients in a convalescent rehabilitation hospital

Roles Formal analysis, Investigation, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliation Department of Occupational Therapy, Tokyo Bay Rehabilitation Hospital, Narashino, Chiba, Japan

Roles Writing – review & editing

Affiliation Department of Occupational Therapy, Teikyo Heisei University, Toshima, Tokyo, Japan

Affiliation Department of Occupational Therapy, Saitama Medical Center, Kawagoe, Saitama, Japan

Affiliation Faculty of Human Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan

• Yuta Asada, 
• Kaori Nishio, 
• Kohei Iitsuka, 

• Published: August 26, 2024
• https://doi.org/10.1371/journal.pone.0309457
• Peer Review
• Reader Comments

This study aimed to explore the stressors experienced by older patients with stroke in convalescent rehabilitation wards in Japan. Semi-structured interviews were conducted with four stroke patients aged > 65 years who experienced a stroke for the first time in their lives. The interviews were analyzed using the Steps for Coding and Theorization method for qualitative data analysis. The results of the qualitative analysis demonstrated that patients experienced specific stressors, such as, difficulty in movement of the paralyzed hand, fear of stroke recurrence, and dietary problems. Some stressors were manageable through healthcare professionals’ active and sensitive communication strategies. These stressors were derived from the theoretical framework of “stressors related to hospitalization” and “stressors related to the illness”. Additional stressors emerged from the interaction between these two types within the theoretical framework. The results of this study contribute to a deeper understanding of the specific stressors experienced by older stroke patients during the recovery process.

Citation: Asada Y, Nishio K, Iitsuka K, Yaeda J (2024) A qualitative study of stressors faced by older stroke patients in a convalescent rehabilitation hospital. PLoS ONE 19(8): e0309457. https://doi.org/10.1371/journal.pone.0309457

Editor: Chinh Quoc Luong, Bach Mai Hospital, VIET NAM

Received: February 24, 2024; Accepted: August 13, 2024; Published: August 26, 2024

Copyright: © 2024 Asada et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Stress is a nonspecific response of the body to external stimuli [ 1 ]. Stress varies as the stressors faced by individuals differ depending on their age, sex, and social role [ 2 ]. Stressors include physical, biological, chemical, psychological, and social factors. The accumulation of these stressors causes stress, which, if not adequately addressed, can lead to physical or mental health problems, such as cardiovascular disease and depression, respectively [ 3 ]. To prevent these stress-related diseases, it is imperative to identify and address the stressors.

Patients often face various stressors in inpatient settings as their physical and human environments differ significantly from those of their regular home settings [ 4 ]. As the length of the hospital stay increases, patients may become particularly vulnerable to stressors such as “concern for family” and “anxiety about financial situation” [ 4 ]. The severity of a stroke, the age of the patient, and the presence of underlying medical conditions are factors that tend to extend the duration of hospitalization [ 5 ]. The incidence of stroke increases with age and is more common among older adults [ 6 ]. Moreover, patients present with a variety of symptoms, such as motor paralysis and higher brain dysfunction, and their ability to perform activities of daily living (ADL) becomes more limited. In particular, convalescent rehabilitation hospitals have a prolonged hospital stay [ 7 ] as one of their goals is to help patients return to the community and their homes.

Much of what is known about stressors related to stroke involves the risk of stroke onset [ 8 , 9 ], and there are insufficient studies on the stressors faced by older stroke patients in hospitals. Clarifying these unspoken stressors can contribute to reducing the stress of hospitalization for older stroke patients during convalescent rehabilitation, meeting their true needs, and enriching their lives after discharge. Few studies have elicited patients’ true feelings regarding stressors in convalescent rehabilitation wards. The purpose of this study is to provide a deeper understanding of the specific stressors experienced by older stroke patients in convalescent rehabilitation wards during their hospital stay.

Materials and methods

We conducted a qualitative study and interviewed each participant separately. The interview transcripts were analyzed according to the “Steps for Coding and Theorization” method (SCAT), a sequential and thematic qualitative data analysis technique [ 10 – 12 ].

This study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ), a checklist designed to improve the transparency and reliability of qualitative research [ 13 ] (S1 Table in S1 File ).

Preparation for the study

The first author (hereafter, “the author”) is a M.S. student in comprehensive human sciences and male occupational therapist with six years of clinical experience in recovery rehabilitation. Before this study was conducted, the author reviewed the literature on SCAT, conducted an analysis, and attended a workshop for SCAT developers to deepen his understanding of the analysis methods to ensure the accuracy of the analysis [ 10 – 12 ].

Participants

Patients aged 65 years or older, experiencing stroke for the first time, and hospitalized in a recovery center were included in the study. Patients who had difficulty answering the interview questions owing to the effects of aphasia, hospitalized patients in the charge of an interviewer, patients diagnosed with dementia or psychiatric disorders, and patients who were hospitalized for a short period of approximately one month were excluded.

Patients were asked to cooperate in the study and fully informed about the purpose and significance of the study, research methods, voluntary nature of research cooperation and freedom to withdraw, and handling of personal information. Signing a consent form indicated patients’ willingness to cooperate in the study.

Interview procedure

Three interviews were conducted between June and November, 2022. The interviewer asked questions according to an interview guide. Semi-structured in-person interviews were conducted in a private room in the hospital that the author is affiliated with, involving the patients and interviewer only. The first interview was conducted at the time of hospital admission, and subsequent interviews were conducted several times, with a gap of approximately one month. The interviews were recorded with the participants’ consent using the voice recorder function of an iPad and transcribed afterwards. The interview transcripts were not returned to participants for comments or correction. The interviewer recited the patients’ statements to them and made efforts to confirm the content of the statements to ensure data accuracy.

The interview guide was developed based on a preliminary survey of two stroke patients to determine ease of response. The content of the interview guide was first explained to the participants through specific examples to help them fully understand the difference between “stress” and “stressors.” The guide began by explaining, through specific examples, what the stressors in this study were. To investigate the stressors faced by older stroke patients in recovery, we asked, “What comes to mind when you hear the term ‘stressors in hospitalization’?”

Data analysis

We predicted that the outcome of the interviews would be strongly influenced by the participants’ individual characteristics. Therefore, to obtain objective results, we used the SCAT technique that specializes in coding and theorization and can be applied to a small amount of data. The SCAT method consists of the following steps [ 10 – 12 ]:

Step 1: Focus words from within the interview texts.

Step 2: Words outside the text that can replace the words from Step 1.

Step 3: Words that explain the words in Step 1 and Step 2.

Step 4: Themes and constructs, including the process of writing a story and offering theories that weave the themes and constructs together.

As this study was designed to create multiple storylines from a single participant, we integrated those multiple storylines into a single storyline and wrote a theoretical description, ensuring no loss of chronological contextuality and individuality of the storylines. The data analysis and confirmation process were conducted by the author and three other authors who were not involved in the interview process.

Ethical considerations

This study was approved by the Ethical Review Committee (Approval No. 289–2) of Tokyo Bay Rehabilitation Hospital.

Basic attributes of the participants

Five participants who met the inclusion criteria were recruited for the study. One participant (female) was excluded owing to early discharge from the hospital on short notice. Thus, four patients (two male and two female) were included in the study. The participants’ average age was 79.3 years (range: 71–88 years). Their disabilities included cerebral hemorrhage (one patient) and cerebral infarctions (three patients).

The average duration of the series of 12 interviews was 20.3 minutes, ranging from 7.5 to 32.7 minutes.

Storyline and theoretical descriptions

In the sections below, the storylines and theoretical descriptions as well as quotes from each participant, are described.

Case 1: Mr. A, facing an inconvenient situation.

At the time of the first interview, Mr. A experienced stress owing to an inconvenient situation during hospitalization. He was unable to perform the activities he did before the onset of the disease, especially owing to the psychological burden caused by the inability to eat and drink according to his preferences. He also expressed dissatisfaction with the current situation, limitations in leisure-time activities, inconvenience of activities, and a sense of shame caused by assistance with bathing. Limited leisure-time activities resulted from challenges in moving his paralyzed hands. He specifically encountered difficulties in willingly engaging them to act. Furthermore, he was separated from his family as a result of hospitalization. Thus, he faced restrictions in eating and drinking luxury foods, lack of freedom in daily life, and lack of family time.

“ Not being able to do things freely is the biggest stressor. All in all, there’s nothing better than that. I can’t eat what I like, or drink a lot. Even if I have a computer, I can’t use my right hand. I can’t even do my own hobbies. And, it is still significant whether or not you have a wife nearby.”

At the time of the second interview, Mr. A experienced stress regarding eating and drinking, including dissatisfaction with the variety of meals compared to before the disease onset, and the psychological burden owing to meals not being replaced on a daily basis. This was also the minimum element that Mr. A looked for during hospitalization. Other stress factors included a feeling of disappointment owing to limited leisure-time activities, and feelings of activity limitation and resignation owing to the inability to walk independently.

“ The most important thing is the food. Anyway, there’s nothing to do, so at least a meal, you’d think, wouldn’t you? The food is different from when we’re at home. It doesn’t help that I can’t walk. And, I think it’s a bit hard not to have hobbies.”

At the time of the third interview, Mr. A expressed that his biggest stress factor was difficulty moving his paralyzed dominant hand. This significantly impacted his daily self-care, including toileting and grooming. He also encountered limitations in various leisure activities, such as reading books. Eating and drinking induced a significant psychological burden. He felt dissatisfied with the lack of variety in meals as he could not manage to eat as well as previously.

“ Whatever I do, my hands don’t work. For example, when you brush your teeth. It’s the same when you go to the toilet and wipe your bottom. I can’t use my right hand. Also, I like books and I want to read, but I can’t turn the pages. And, unlike in the past, I eat rice and side dishes every day. My eating habits have changed drastically.”

Case 2: Ms. B, facing stressors caused by communal living.

At the time of the first interview, Ms. B faced stressors related to basic lifestyle habits, such as falling asleep and toileting, in the hospital. Variations in individual lifestyles and environmental factors, like noise and room brightness, contributed to sleep deprivation in shared living arrangements. Furthermore, inadequate management of the paralyzed side during sleep led to anxiety and sleep deprivation. Problems related to toileting needs arose owing to overlap in toilet timings with roommates and assisted by staff of the opposite sex.

“ I sometimes have trouble sleeping well at night because of noises or brightness. Everyone is trying to go to the toilet before rehabilitation, so the timing is… And with male nurses, there was a bit of resistance to using the toilet. After all, in shared living arrangements, everyone has a different rhythm of life.”

During the second interview, Ms. B continued to face stress owing to communal living. Stressors included abnormal breathing noises caused by roommates when falling asleep, noise problems during roommates’ movements, and nocturnal awakenings caused by physical environmental factors such as differences in depth of sleep. Additionally, there were case of sleep problems caused by the staff’s response to a roommate’s problematic behavior, and case of nocturnal awakenings caused by noise from staff responses. Other issues included self-perceived persistent distress over defecation problems and dealing with defecation needs in a time-constrained environment, with a roommate.

“ Like last time, in shared living arrangements, everyone has a different rhythm of life, but it can’t be helped. Sleep, you know, because some people go to the toilet at night or early in the morning, so it’s quite noisy and you can’t sleep well. And the nurse puts the patient next to me to sleep, and there are all sorts of noises when she does that. We all have the same desire to go to the toilet before rehabilitation, so we don’t make it in time. Toilets are a perpetual problem.”

At the time of the third interview, Ms. B had problems with how he interacted with his roommates and stressors related to falling asleep at night. Ms. B was dissatisfied with differences in personal characteristics in communal living, and concerned about the deterioration of his relationship with his roommates over defecation. Furthermore, stress was caused by differences in lifestyle in communal living affecting sleep and awakening during the night owing to physical environmental factors such as noises made by roommates. Sudden changes in training hours also caused dissatisfaction.

“ Like how to communicate with people in the room. Like sleeping. Because of the lights and noise when my roommate goes to the toilet at night. Roommates have different living patterns. In rehabilitation, though, there were some questionable things like time changes.”

Case 3: Ms. C, facing an excrement problem and anxiety about stroke recurrence.

At the time of the first interview, Ms. C faced the problem of excrement in communal living. Dissatisfaction was caused by the suppression of excretory behavior and rejection of excretion in communal living, leading to anxiety. There were also conflicts and a psychological burden caused by the staff’s lack of information sharing, which led to restraining from defecating after unpleasant experiences.

“ I don’t like the situation of one toilet for four people. I and others are suffering. I thought it was hard. I didn’t know that you have to press the nurse call. Then I wished they had told me from the beginning. That was a bit of a shock.”

At the time of the second interview, Ms. C expressed dissatisfaction with their lack of independence in elimination. This led to a sense of aversion caused by dealing with the need to defecate frequently during the night and self-consciousness about requests for nighttime defecation assistance, which, in turn, led to resisting the need to defecate, a distressing experience unique to the patient.

“ I feel bad because I have to go to the toilet in the middle of the night. But I try to be patient. If it was during the day, I would ask the nurse to help me, but at night I would still feel sorry. It’s painful. You have to be experienced to understand.”

At the time of the third interview, Ms. C was anxious about the gap between their life at home after discharge and their life in the hospital and about the gradual decline of their brain functions. They also experienced anxiety owing to the fear of stroke recurrence and an undecided medical support system for the prevention of recurrence. These stressors were related to worry caused by a lack of information sharing by the staff and delays in sharing information about discharge from the hospital.

“ I have a little bit of anxiety about my future and my life. Because I’ve got comfortable here. And I don’t know what I would do if I fell ill again. No one is going to talk to me about it. I’m a bit worried about that. That’s what I’m most worried about.”

Case 4: Mr. D, facing a meal problem.

At the time of the first interview, Mr. D expressed their stress that they had to hold their toileting until the hospital staff arrived when they needed to defecate. This occurred as the hospital staff were extremely busy, and they experienced failure in excretory management. However, at the time of the interview, they were able to use the toilet independently.

“ I’ve had a leak before the nurse came. She can’t come right away, she’s too busy. It’s gone now.”

At the time of the second interview, Mr. D had a low appetite owing to low-temperature meals and refused to eat as a result of inappropriate meal temperature. Additionally, there were difficulties with grooming movements around the use of the wash basin and dealing with the need to defecate in communal living.

“ The rice and side dishes are cold. So I feel sorry to leave it. I can eat it beautifully when it’s warm. But when it’s cold, I just can’t. After the meal, I can’t wash my hands because some people wash their hands in their rooms first. When I want to go into the toilet, there are people ahead of me. It can’t be helped.”

In the third interview, Mr. D felt stress when the meal was not hot enough to eat and lost their appetite. He also felt stress when his mealtime was delayed as it that cause would take time for them to do their personal grooming after returning to their room where their roommate occupied t the wash basin.

“ Side dish is cold. Wish it was room temperature. I eat my meals late, so I’m the last one to go back to my room. So, I can’t wash my hands first.”

In this study, semi-structured interviews were conducted to identify the stressors faced by older patients with stroke during convalescent rehabilitation, throughout hospitalization; data analysis was conducted using SCAT.

Based on the storylines and theoretical descriptions, the stressors experienced by stroke patients were categorized into “stressors related to hospitalization” and “stressors related to the illness” [ 4 ].

Stressors related to hospitalization

The results of this study revealed that older stroke patients in convalescent rehabilitation face stressors related to ADLs, such as eating, sleeping, grooming, and toileting; leisure activities; problems with roommates in communal living; and inability to be with their family members. In this study, the first interview was conducted at the time of admission, and stressors were reported by all participants. Stress during hospitalization is caused by the fact that patients are forced to live a life with less freedom than before [ 4 ].

The psychological burden is particularly high for older adults as they have a reduced ability to adapt to changes in the external environment compared with younger patients [ 14 ]. In light of the above, older stroke patients may face a variety of stressors from the early stages of hospitalization compared with younger patients; therefore, intervention against these stressors is necessary from the early stages of hospitalization.

Factors such as relationships with roommates may lead patients to experience discomfort [ 15 ], and the way patients relate to their roommates is considered important. In this study, physical environmental factors caused by differences in lifestyle and the timing of toilet and wash basin use with roommates emerged as stressors. Additionally, these factors affected the participants’ ADL, such as grooming, toileting, and sleeping. Considering these findings, it is important for patients living together to consider each other’s needs. Therefore, it is necessary for patients to communicate with each other to deepen their understanding, and healthcare professionals are expected to play a role in building such relationships.

Furthermore, stressors such as meal variations and meal temperature emerged rather than stressors such as taste and preference. Older people tend to experience a decline in dietary variety owing to a decline in physical and oral functions and appetite [ 16 ]. Moreover, older patients undergoing treatment for cerebrovascular disease are more likely to experience changes in food preferences than younger patients [ 17 ], which is not consistent with the results of the present study. Given that the amount of food intake in a hospital setting is linked to the quality of food, including taste and the dining environment [ 18 , 19 ], there is a need for further research on qualitative aspects of meal preparation, such as food variations and appropriate temperatures. However, studies on meal variations and temperature are limited. In the future, these should be investigated in detail as characteristic stressors faced by older stroke patients during convalescent rehabilitation.

Stressors related to the disease

The results revealed that older stroke patients in rehabilitation face stressors such as difficulty moving the hand affected by motor paralysis, recurrent strokes, lack of information given by healthcare providers, and inappropriate actions or words of healthcare providers. Approximately 50% of stroke survivors experience unilateral motor paralysis [ 20 ]. Improvement in motor paralysis of the upper limbs and fingers contributes to greater independence in ADL [ 21 , 22 ]. It not only affects ADL but a wide range of activities, such as housework and leisure activities [ 23 , 24 ].

In this study, there were patients whose hobbies were limited by difficulty in moving the paralyzed hand. Additionally, based on the interviews at the time of admission, activity limitation caused by paralysis was a stressor faced from the time of admission itself. Therefore, early interventions and psychological support are needed for patients with paralysis.

A lack of information about the disease may also increase patient anxiety and cause dissatisfaction among healthcare providers [ 4 ]. Stroke recurs at a rate of 2.2% to25.4% within one year of disease onset, 12.9% within two years, and approximately 16% within five years [ 25 ]. Therefore, it is important to support stroke patients to prevent recurrence [ 26 ]. The participants were interviewed before discharge from the hospital about stressors such as recurrent stroke and lack of information provided by healthcare providers. This suggests that providing information to older patients with stroke undergoing convalescent rehabilitation to prevent recurrence is very important, especially for patients who are about to be discharged from the hospital, and that a lack of information can cause stress. Furthermore, communication between stroke patients and healthcare professionals does not always match [ 27 ]. Efforts should be made to prevent a lack of information, considering the patient’s cognitive function and the degree of higher brain dysfunction.

Additionally, stressors such as the personal care of patients by healthcare professionals of the opposite sex, and behaviors and words caused by misunderstandings on the part of healthcare professionals emerged. Patients may experience discomfort and high psychological distress owing to factors such as the attitudes and actions of healthcare workers [ 16 , 28 ]. An inadequate explanation or lack of consideration of shame may also arouse anger in patients [ 29 ]. Stroke patients are placed in a situation where they are prone to feelings of shame owing to assistance with ADL such as bathing and toileting. Therefore, healthcare professionals must be sensitive to patients when providing daily care. Stress can be prevented through appropriate attitude and information sharing.

Various symptoms, such as motor paralysis, sensory disturbance, higher brain dysfunction, and cognitive decline, appear as post-effects of stroke. The complex interplay between these symptoms causes a decline in the ability to perform ADL [ 30 – 32 ]. In this study, there were patients for whom difficulty in achieving independence in ADL was a stressor. Patients with higher levels of ADL independence had higher self-efficacy, and successful experiences were effective in forming self-efficacy [ 33 ]. This principle should be applicable to older stroke patients in convalescent rehabilitation hospitals. The positive outcomes of their hospital experience may be partially attributed to reduced stress.

Additionally, some patients faced limitations in self-care, stressors related to hospitalization owing to the aftereffects of stroke, and stressors related to illness. Given these findings, it was suggested that stroke patients may have been stressed by the interaction of “stressors related to the disease” and “stressors related to hospitalization.” However, if one of these stressors can be adequately addressed, it is likely that related stressors can be reduced.

Limitations

In conclusion, we clarified the stressors faced by older stroke patients in convalescent for rehabilitation. However, this study has some limitations. First, the study was severely limited by the small number of patients, which prevents us from drawing some important conclusions. The SCAT method can be used to analyze data from a small number of people because it provides a theoretical description from the participants’ storylines; however, the number of participants in this study was not sufficient to generalize the findings. Second, this study did not fully consider the participants’ individual characteristics, such as personality and background, nor did it analyze the patients in terms of their pathology and sequelae. Therefore, the results obtained should be interpreted carefully, as individual bias was not sufficiently eliminated. In future, it is necessary to select other participants and data analysis methods that consider participants’ individual characteristics and the aftereffects of stroke and recruit more participants to elucidate the stressors faced by older stroke patients in convalescent rehabilitation.

Stressors specific to older stroke patients were identified, including difficulty moving the paralyzed hand, recurrent stroke, and diet-related stressors. Stressors identified in this study can be broadly classified into “stressors related to hospitalization” and “stressors related to the disease,” consistent with previous studies [ 4 ]. However, it was found that stress is also caused by the interaction between “stressors related to hospitalization” and “stressors related to the disease.” To the best of our knowledge, thus far, no reports have identified the specific stressors faced by older stroke patients. Therefore, this study provides valuable information from a first-hand perspective that will lead to a deeper understanding of the specific stressors experienced by older stroke patients during recovery. Future studies should explore how various stressors lead to stress in older stroke patients at various types of rehabilitation hospitals.

Supporting information

S1 file. consolidated criteria for reporting qualitative studies (coreq): a 32-item checklist..

https://doi.org/10.1371/journal.pone.0309457.s001

Acknowledgments

We thank all the participants who agreed to be interviewed for this study. We also thank the members of the Rehabilitation Science Degree Program, Graduate School of Comprehensive Human Sciences, University of Tsukuba, for their guidance and encouragement during this study.

• View Article
• PubMed/NCBI
• Google Scholar

Stroke Case Study Academic Essay

Introduction Stroke is described as a common disease, which is as well referred to as CVA (Cerebrovascular Accident). The condition is typified by extraordinary injury of the function of the brain because of hindered supply of blood to the tissues of the brain. Usually, the disease is managed as a medical emergency, which can at times cause the death of a person. The resultant hindrances of blood flow to the tissues of brain limit the brain of sufficient nutrients that as a result makes the brain incapable of carrying out its vibrant activities as a consequence of the incapability of receiving adequate blood (Agbor-Etang & Setaro, 2015; Boorstein 2011). This paper focuses on the case study of Mrs. Greta Balodis, a 75 year-old widow who has been experiencing deterioration in her health over the past two years incapacitating her normal activities. She is diagnosed with right-sided cerebrovascular accident (CVA). Background Information Greta presented with headache, drooping of her face and mouth on the side, weakness of her left arm and leg, dizziness and nauseous. She was then diagnosed with Right cerebral vascular accident (CVA) and atrial fibrillation. After spending two weeks in the acute care hospital and six weeks at the specialist stroke rehabilitation, she was discharged with mild residual Left sided hemiplegia and resolving dysphagia. On discharge, she was put on Aspirin PO 100mg daily Clopidogrel PO 75mg daily Digoxin 125mcg PO daily. Currently she is doing fine. She is on home rehabilitation program receiving regular in-home physiotherapy with a nurse visiting her once a week. She manages to mobilize short distances with a three-pronged stick. Pathophysiology of Cerebrovascular Accident (Stroke) and How It Affects the Central Nervous System (CNS) The CNS is often is affected by cardiac conditions or by very similar pathologic processes, which affect the heart. Many diverse heart diseases are capable of producing CNS dysfunctions signs and symptoms (Mohr et al. 2011). Due to Gretas presentation and history, definitely he was suffering from an embolic stroke. Cerebral embolism patients typically present with an acute, neurologic deficit. Occasionally, headache may ensue just earlier or together with the development of the deficit. Emboli lodge in the vessels supplying blood to the brain reducing supply of blood. Frequently seizures are the common initial presentation (Mohr 2011). Greta for instance had a history of falls (three in last six months) and TIA in 2012. Often, cerebral embolism ensues during vigorous activity. Apart from Gretas arterial fibrillation, other causes of cerebral embolism include MI (Myocardial infarction); Left-ventricular aneurysm; RHD (Rheumatic heart disease); infectious endocarditis; cardiomyopathy; thyrotoxicosis; cardiac cancers; mitral valve prolapse; and CHD (Congenital heart disease) among others. Pathophysiology of Embolic Stroke Ischemic stroke is usually is as a result of blood supply to a part of the brain that ultimately stops working. Ischemia is capable of being caused in the brain as a result of thrombotic plaque, which prevents the blood vessels blocking communication via the blood vessel (Gasecki, Karaszewski & Narkiewicz 2016). On the other hand, embolism may result to blockage of blood vessels. Perhaps emboli may be moved from whichever body part and dislocated in a substantial portion of the brain thus stopping blood flow to the brain. Moreover, decreased the supply of blood similar to shock; may lead to a person to CVA. Ischemic stroke is capable of being extremely acute in definite instances. Nonetheless, cryptogenic stroke (unknown type) also leads to a huge percentage of the whole strokes types (Mohr et al. 2011). The etiology of Ischemic strokes is blood clots. Ischemic stroke is of two types: thrombotic and embolic. An embolic CVA takes place at the time a blood clot, which forms somewhere else in the body (embolus), is dislodged and moves to the brain through the circulation. Ultimately, the embolus lodges in vessels and blocks blood the flow resulting to CVA (Campbell2010). Pathophysiology Blood clots resulting to embolic CVA can form in any part of human body, but usually originate from the heart or upper chest and neck arteries. Following dislodge the clot moves via the circulation to the brain. However, after entering a small brain vessel, it stuck obstructing the blood flow to the brain (Grotta et al. 2015). Emboli can result from fat globules, air bubbles, or an arterial plaque. However, emboli can as well arise from abnormal heartbeat (for instance atrial fibrillation); a disorder that the heart fails to beat efficiently, resulting to pooling and clotting of blood (Siniscalchi et al. 2015). Gretas CVA was as a result of this. In most cases, the mechanism ischemic stroke is a significant characteristic and aids in the prediction of results after stroke and consider stroke recurrence risk. There are five classification structures of ischemic strokes etiologies, which has turned out to be extensively acknowledged: embolism, large-artery atherosclerosis, CVA of other determined cause, small-vessel disease, as well as stroke of undetermined cause (Galvagno 2013). In the case of Greta, the cause of facial drooping and weakness was as a result of cardiac embolism. This is referred to as Bells palsy: is a type of transitory facial paralysis due to damage to the facial nerves. Turbulent or still flow conditions in the heart causes thrombi formation. The thrombi dislodge and block vessels in the intracranial flow past downstream. The significant cardioembolic stroke cause is atrial fibrillation (Galvagno 2013). Risk Factors Persons with heart diseases are at higher risk of developing embolic stroke. Consistent withGrotta et al. (2015), atrial fibrillation forms 15% of embolic CVAs. Persons with a familial history of CVA, or who have before experienced a mini-stroke remain at higher risk (Grotta et al. 2015).Other risk factors are older age (Greta Balodis 75 years old);Hypertension (Greta Balodis is Hypertensive); high cholesterol; diabetes; autoimmune diseases; smoking (Greta Balodis is a passive smoker); and obesity (J??rgense, Nakayama, Raaschou, Pedersen, Houth & Olsen 2015). In short, factors that may have precipitated Gretas stroke are previous history of TIA, hypertension, atrial fibrillation, passive smoking, and obesity (Greta is obese her BMI is 34.96: height 1.55m and weight 84kg). Management of Stroke Medical treatment Anticoagulation; patients with cerebral embolism episode are required to be anti-coagulated primarily with heparin (7-10 days) and later on warfarin provided the predisposing heart disease lasts. Anti-coagulation should be avoided in patients with infectious and infectious endocarditis or cardiac cancers. TIAs patients often respond well from daily aspirin, 650 mg BD; clopidogrel, 75mg OD; or Aggrenox) (Spence & Hammond 2016). Also, TIA patients will have less attack in case they are managed with warfarin; nevertheless, warfarin treatment has an increased bleeding complications risk compared to aspirin (Aiyagari & Gorelick 2011). For reduction of risk factors, patients are given therapy targeted at reducing the risk factors for instance management of hypertension. Greta Balodis was discharged with Aspirin PO 100mg OD and Clopidogrel PO 75mg OD for TIA and Digoxin 125mcg PO OD to manage hypertension. However, the current medication Atenolol PO 50mg daily is for the management of hypertension and Panadol PO 500mg prn is for the management of pain. Pharmacology Thrombolytic, more precisely, fibrinolytic agents convert captured plasminogen to plasmin as well as binding to clot fibrin leading local fibrinolysis. Alteplase is a t-PA utilized in the management of acute MI, acute pulmonary embolism, and ischemic stroke. However, aspirin administration prevents prostaglandin synthetase activity that later on bars synthesis of prostaglandin and prevents the creation of platelet-aggregating thromboxane A2 (Jones & Riazi 2011). Similarly, it works on the hypothalamic heat-regulating centre to diminish fever. On the other hand, Clopidogrel prevents aggregation of platelet and is utilized for the prevention secondary CVA (Gasecki, Karaszewski, & Narkiewicz, 2016). Acetaminophen lessens high temperature by acting on hypothalamic heat-regulating centres directly by raising the body heat dissipation through sweating and vasodilation. Atenolol, an adrenergic receptor-blocking agent produces dose-related reductions in hypertension without bringing down reflex tachycardia (Aiyagari & Gorelick 2011). Conclusion Greta presented with headache, drooping of mouth and eye, dizziness and nausea. Sudden trouble in walking, dizziness occurs as a result of injury to inner-ear nerves. Similarly, this may cause nausea, wobbliness on the feet, a propensity to turn to one side or the other, or a mysterious fall. Headache result from due to meningeal stretching or irritation. The present management of Greta with Atenolol PO 50mg OD and paracetamol when necessary were prescribed for the management of hypertension and pain respectively. Aspirin was given 100mg along with Clopidogrel 75mg per oral for the management of TIA. On the same note, the earlier prescription of Digoxin was to manage hypertension. Bibliography Agbor-Etang, BB, & Setaro, JF 2015, Management of hypertension in patients with ischemic heart disease, Current cardiology reports, vol. 17, no. 12, pp. 1-7. Aiyagari, V, & Gorelick, PB 2011, Hypertension and stroke: Pathophysiology and management, Humana Press/Springer, New York. Boorstein, S 2011, Different strokes: An intimate memoir for stroke survivors, families, and caregivers, Skyhorse Pub, New York, NY. Campbell, J 2010, Different strokes, different people, Lulu Com, S.l. Galvagno, SM 2013, Emergency pathophysiology: Clinical applications for prehospital care: Samuel M, Teton NewMedia, Galvagno Jr. Jackson, Wyo. Gasecki, D, Karaszewski, B, & Narkiewicz, 2016, Management of High Blood Pressure in Acute Ischaemic Stroke, In Hypertension and Brain Damage (pp. 143-158), Springer International Publishing. Gasecki, D, Karaszewski, B, & Narkiewicz, K 2016, Management of High Blood Pressure in Intracerebral Haemorrhage, In Hypertension and Brain Damage (pp. 159-171), Springer International Publishing. Grotta, JC, Albers, GW, Broderick, JP, Kasner, SE, Lo, EH?? & Sacco, RL?? & Wong, LK, 2015, Stroke: pathophysiology, diagnosis, and management, Elsevier Health Sciences, London. Jones, F, & Riazi, A 2011, Self-efficacy and self-management after stroke: a systematic review, Disability and rehabilitation, vol. 33, no. 10, pp. 797-810. J??rgense, HS., Nakayama, H, Raaschou, HO, Pedersen, PM, Houth, J, & Olsen, TS 2015, Functional and neurological outcome of stroke and the relation to stroke severity and type, stroke unit treatment, body temperature, age, and other risk factors: The Copenhagen Stroke Study, Topics in stroke rehabilitation. Mohr, JP, 2011, Stroke: Pathophysiology, diagnosis, and management, PA: Elsevier/Saunders, Philadelphia. Mohr, JP, Grotta, JC, Wolf, PA, Moskowitz, MA, Mayberg, MR, & Von Kummer, R 2011, Stroke: pathophysiology, diagnosis, and management, Elsevier Health Sciences, London. Siniscalchi, A, Bonci, A, Biagio Mercuri, N, De Siena, A, De Sarro, G, Malferrari, G., ?? & Gallelli, L 2015, Cocaine dependence and stroke: pathogenesis and management, Current neurovascular research, Vol. 12, no. 2, pp. 163-172. Spence, JD, & Hammond, R 2016, Hypertension and stroke, In Hypertension and the Brain as an End-Organ Target (pp. 39-54), Springer International Publishing.

Use the order calculator below and get started! Contact our live support team for any assistance or inquiry.