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Case Study: Yun's Right-Sided Thrombotic Cerebrovascular Accident

Q.1. Cerebrovascular accident is a term used to describe stroke which can lead to acute or permanent brain damage (Ojaghihaghighi et al., 2017). Stroke is a medical condition that influence walking, speaking and understanding. Cerebrovascular accident can be a result of several risk factors.

These risk factors include:

  1. High blood pressure: increase in the blood pressure or hypertension is one of the most common risk factor for cerebrovascular accident or stroke (Ojaghihaghighi et al., 2017). Hypertension increase the burden on heart in the form of increased workload in the arteries. This lead to damage in the arteries which further reduce the availability of oxygen in the brain cells. This further increase the probability of a person to experience stroke.

  2. Heart disease: Heart disease such as left sided or right sided heart failure lead to inability of the heart. The inability is seen in the heart function to pump required amount of blood in the body (LIWA, OPIE & TEERLINK, 2019). The blood follows in the body in the form of both the oxygenated and deoxygenated blood. The oxygenated blood carries to tissues and organs and the deoxygenated blood brings carbon dioxide from the tissues and organs to lungs. Inability of pumping enough blood by the heart reduce the amount of oxygenated blood and this lead to oxygen deficiency in the brain. Lack of oxygen further results in stroke or cerebrovascular accident.

  3. Personal or family history of stroke: Family or personal history acts as a major risk factor for stroke. Genetic conditions such as sickle cell anemia, increase the risk of a person to develop stroke (LIWA, OPIE & TEERLINK, 2019). Family history develops environmental conditions that impact stroke and risk of stroke. Personal exposure to stroke in the past also increase the risk of having a stroke in future.

  4. Smoking: smoking can induce heart diseases, hypertension and a condition known as atrial fibrillation which increase the risk of stroke.

Q.2. Cerebrovascular accident is a medical term used to define a stroke. A stroke is a condition when a blockage or a collapse of a blood vessel prevents blood flow to a part of the brain (Schmid et al., 2019). The brain is considered as the body's primary information-processing organ and it is responsible for regulating several complex functions in the body. Stroke inhibits the blood supply in brain and then the brain cells start to die which leads to brain damage. Stroke is basically a type of brain injury that is caused by an unexpected disruption in the brain's blood supply. It usually happens when region of the brain does not obtain the required blood flow for one of two reasons. These reasons either involve interrupted blood supply to part of the brain or because a blood vessel breaks and blood invades the surrounding areas of the brain (Schmid et al., 2019).

“The anatomical studies of brain have revealed that blood is carried to the brain through the internal carotid arteries and vertebral arteries”. A single basilar artery is formed by the right and left vertebral arteries. The middle cerebral artery is the most usually blocked artery due to oxygen deficiency in brain. Strokes can lead to loss of sensation, speaking difficulty, walking and seeing issues because of oxygen deficiency in the brain (Ebihara et al., 2020). Presence of a blood clot can also block an artery or part of brain and since every part of brain has a characteristic function so the function is impaired which often result in a stroke. During a thrombotic cerebrovascular accident the brain does not receive required blood. This disturb the aerobic metabolism of the brain cells. Impaired aerobic metabolism lead to cell death which result in permanent disability or death.

Q.3. Both the ischemic and hemorrhagic strokes has the ability to bring devastating clinical outcomes although they have different pathophysiology. According to (Hatleberg et al., 2019), ischemic strokes are more common in comparison to the hemorrhagic stroke as 80 out of 100 strokes are ischemic strokes. An ischemic stroke is a condition in which a blood clot usually blocks an artery which supplies blood to an area of the brain. However, a hemorrhagic stroke is a condition in which an artery ruptures or leaks in the brain. The Intracerebral hemorrhage comprises of 10-15% of the total strokes and it occurs from conditions such as increased blood pressure. Increase in the blood pressure can exert greater pressure on the arterial walls (Sommer, 2017).

These strokes are common in people in which the arterial walls are already impaired because of conditions such as aneurysm, arteriovenous malformation and atherosclerosis. However, the ischemic strokes which are also known as cerebral infarcts results due to emboli development in the brain. Emboli lead to blockage and this brings up oxygen deficiency in tissues. Reduced oxygen circulation in the brain lead to neuronal cellular injury and it also brings inflammatory response and neuronal death. Major difference between the ischemic and hemorrhagic stroke is that the ischemic stroke represents and reflects the diffused cerebral vascular pathology (Sommer, 2017). However, the hemorrhagic stroke enhance the exposure of brain to harmful effect of blood.

figure illustrates difference between ischemic stroke and hemorrhagic stroke in which a clot blocks blood flow in ischemic stroke and rupture of blood vessels brings up exposure of brain cells to irritating effects of blood in hemorrhagic stroke

(Source: Staff, H. 2018)

(Fig1: difference between ischemic stroke and hemorrhagic stroke in which a clot blocks blood flow in ischemic stroke and rupture of blood vessels brings up exposure of brain cells to irritating effects of blood in hemorrhagic stroke.)

Q.4. The clinical manifestations of cerebrovascular accident can differ from individual to individual (Ettehad et al., 2016). The symptoms can appear suddenly and they can get severe over time. Some of the clinical manifestations for both ischemic and hemorrhagic stroke include:

  • Dizziness

  • Left sided facial drop

  • Balance and coordination loss

  • Darkened and blurred vision

    Sudden onset of Headache which is often accompanied by vomiting, nausea and dizziness

  • Left sided weakness in arm and leg

  • Paralysis in the leg, arm, and face. Patients experiencing a stroke also face one sided body paralysis.

  • Difficulty in walking

  • Difficulty in speaking and understanding what others wants to speak

Yun is a 79 years old male who is experiencing severe symptoms of left-sided arm and leg weakness, followed by left-sided facial drop and slurred speech. He also experienced sudden onset of severe headache which is one of the most common clinical manifestation of a stroke. People experiencing stroke usually appear these symptoms before actually having a stroke. Yun is experiencing these symptoms in addition to previous history of 2 ischemic strokes which indicate his vulnerability to get another potential cerebrovascular accident.

Q.5. The FAST assessment tool can be used to assess a person with potential cerebrovascular accident (Williams et al., 2017). It is also known as the Face Arm Speech Test. It is a 3-item stroke assessment tool which is used to assess speech disturbance, facial weakness and arm weakness. Presence of more than one condition in a person can depict possibility of a stroke. Ultimately, it is an acronym which is used to classify all the symptoms of stroke. The FAST assessment tool is used to identify a stroke in emergency patients (Nogueira et al., 2017). The FAST acronym can be described as:

  • Face: it involve questions such as “Does one side of the face droop?”

  • Arm: analysis of the arms in which the assessor assess the arms of the patient. If a patient hold both the arms together, so does one arm drift downward?

  • Speech: slurred or abnormal speech?

  • Time: presence of any of these symptoms brings out the need to call the ambulance or 911 services.

If I suspect a person of having a stroke then I will use a FAST assessment tool to identify the early warning signs. Primarily I will check for facial weakness then I will check arm weakness. Further I will analyze speech impairment and then call 911 immediately. Facial weakness, weakness in left hand and leg and blurred speech are the most common symptoms of stroke. Timely recognition of these symptoms can prevent patients from serious morbidity and mortality.

Q.6. Actual health issues that can impact Yun

The actual health issue that can impact the health of Yun is previous medical history of transient ischemic attacks. The transient ischemic attack have same origin to that of the ischemic stroke (Panuganti, Tadi & Lui, 2019). Both the transient ischemic attack and an ischemic stroke have a blockage in the artery that lead to reduced blood flow and further cause brain damage. However, the brain damage caused by transient ischemic attack is temporary and it can have short term effects on the patients. According to Panuganti, Tadi and Lui (2019), transient ischemic attacks are mainly associated with some underlying cerebrovascular disease. So, it can be considered as an ongoing health issue for Yun.

Potential health issues that can impact Yun

Potential health issues that can impact Yun include hypertension, obesity, lack of physical exercise and diet rich in salt intake. Hypertension or increase in salt intake in the diet can damage the blood vessels (Santisteban & Ladecola, 2018). It ca narrow down, leak and rupture the blood vessels during prolonged exposure. High blood pressure can result in blood clots in the arteries which can be a potential case of stroke. Obesity and lack of physical exercise increase the impact of hypertension and hence it can increase the probability of stroke.

Q.7.

  • Hemi neglect is very common after a right hemisphere stroke. Moreover, it prevents functional independence in patients in which effective rehabilitation interventions are lacking. Support services that provide assistance with daily living activities for the patient can be helpful during the discharge (Ibrahim et al., 2018). The left sided hemiplegia and neglect can be maintained by technologies such as visual-acoustic alarm. The visual acoustic alarm can be activated by certain movement discrepancy in both hands and it can be used in a hemi neglect arm for enhancing use of neglect arm in daily living activities.

  • Stroke can impact the emotional behavior of a person because it impact important areas of the brain. It can make the patients impulsive, aggressive, depressed, anxious and angry. It is important for the patient to have enough emotional and mental support after or during recovery (Krause et al., 2017). Support from mental health services can help a patient get easy discharge after the condition. Yun can be helped for his impulsive behavior by support from the GoodTherapy services.

  • Patients with stoke have impaired judgment abilities. Stroke not only impact the brain internally but also alters its functions externally (Krause et al., 2017). Yun cannot make judgements for his own life after the procedure because of his impaired judgments. He need acute assistance with his emotional stability and judgement abilities. A family member can be best suited for this. Although, statewide clinical support services can be assessed for making decisions related to patient behavior.

Q.8. The potential risk factors for Yun suffering from a cerebrovascular accident include:

  • Previous transient ischemic attacks: previous transient ischemic attacks are a result of underlying cerebrovascular disease and it increase the risk of stroke (Herrod et al., 2018).

  • Being obese or overweight: increase in weight develop risk of high blood pressure which increase the risk of stroke.

  • Poor diet rich in salt: “diet rich in salt and saturated fats can narrow down the arteries and it can develop the risk of developing obstructions in the arteries and hence stroke (Herrod et al., 2018)”.

  • Lack of physical exercise; lack of physical exercise lead to increased risk of hypertension and obesity and this can bring up conditions of stroke.

  • Hypertension or increased blood pressure: high blood pressure is one of the most significant risk factor for cerebrovascular accident. It increase the damage to the blood vessels in the brain which leads to a stroke.

Modifiable risk factor that can reduce the risk of cerebrovascular accident for Yun include diet rich in salt and lack of physical exercise. Cutting of salt from the diet and enhancing physical exercise in life style can reduce high blood pressure and it can ultimately reduce the risk of cerebrovascular accident (Liao et al., 2016).

Reference

Ebihara, K., Yamagishi, K., Umesawa, M., Muraki, I., Cui, R., Imano, H., ... & Sankai, T. (2020). Moderate Levels of N-Terminal Pro-B-Type Natriuretic Peptide is associated with Increased Risks of Total and Ischemic Strokes among Japanese: The Circulatory Risk in Communities Study. Journal of Atherosclerosis and Thrombosis, 52241

Ettehad, D., Emdin, C. A., Kiran, A., Anderson, S. G., Callender, T., Emberson, J., ... & Rahimi, K. (2016). Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet, 387(10022), 957-967

Hatleberg, C. I., Ryom, L., Kamara, D., De Wit, S., Law, M., Phillips, A., ... & Kirk, O. (2019). Predictors of ischemic and hemorrhagic strokes among people living with HIV: the D: A: D international prospective multicohort study. EClinicalMedicine, 13, 91-100.

Herrod, P. J., Doleman, B., Blackwell, J. E., O’Boyle, F., Williams, J. P., Lund, J. N., & Phillips, B. E. (2018). Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis. Journal of the American Society of Hypertension, 12(4), 248-267.

Ibrahim, N. I., Ahmad, M. S., Zulfarina, M. S., Zaris, S. N. A. S. M., Mohamed, I. N., Mohamed, N., ... & Shuid, A. N. (2018). Activities of daily living and determinant factors among older adult subjects with lower body fracture after discharge from hospital: a prospective study. International Journal of Environmental Research and Public Health, 15(5), 1002.

Krause, M. R., Zanos, T. P., Csorba, B. A., Pilly, P. K., Choe, J., Phillips, M. E., ... & Pack, C. C. (2017). Transcranial direct current stimulation facilitates associative learning and alters functional connectivity in the primate brain. Current Biology, 27(20), 3086-3096.

Liao, Y., Siegel, P. Z., White, S., Dulin, R., & Taylor, A. (2016). Improving actions to control high blood pressure in Hispanic communities—racial and ethnic approaches to community health across the US project, 2009–2012. Preventive Medicine, 83, 11-15.

Nogueira, R. G., Silva, G. S., Lima, F. O., Yeh, Y. C., Fleming, C., Branco, D., ... & Bouslama, M. (2017). The FAST-ED App: a smartphone platform for the field triage of patients with stroke. Stroke, 48(5), 1278-1284.

Ojaghihaghighi, S., Vahdati, S. S., Mikaeilpour, A., & Ramouz, A. (2017). Comparison of neurological clinical manifestation in patients with hemorrhagic and ischemic stroke. World Journal of Emergency Medicine, 8(1), 34.

Panuganti, K. K., Tadi, P., & Lui, F. (2019). Transient ischemic attack. In StatPearls [Internet]. StatPearls Publishing.

Santisteban, M. M., & Iadecola, C. (2018). Hypertension, dietary salt and cognitive impairment. Journal of Cerebral Blood Flow & Metabolism, 38(12), 2112-2128.

Schmid, F., Barrett, M. J., Jenny, P., & Weber, B. (2019). Vascular density and distribution in neocortex. Neuroimage, 197, 792-805.

SLIWA, K., OPIE, L. H., & TEERLINK, J. R. (2019). Acute versus Chronic Heart Failure. Drugs for the Heart, 6180.

Sommer, C. J. (2017). Ischemic stroke: experimental models and reality. Acta Neuropathologica, 133(2), 245-261.

Williams, T. A., Blacker, D., Arendts, G., Patrick, E., Brink, D., & Finn, J. (2017). Accuracy of stroke identification by paramedics in a metropolitan prehospital setting: a cohort study. Australasian Journal of Paramedicine, 14(2).

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