You are on page 1of 34

CASE

PRESENTATION
Maureen Allysandra J. Gamboa
Cerebrovascular Disease

■ The word cerebrovascular is made up of two parts – "cerebro"


which refers to the large part of the brain, and "vascular"
which means arteries and veins. Together, the word
cerebrovascular refers to blood flow in the brain. The term
cerebrovascular disease includes all disorders in which an
area of the brain is temporarily or permanently affected by
ischemia or bleeding and one or more of the cerebral blood
vessels are involved in the pathological process.
Cerebrovascular disease includes stroke, carotid stenosis,
vertebral stenosis and intracranial stenosis, aneurysms, and
vascular malformations.
Acute CVD
■ Damage most often can cause
changes in:
– Movement and sensation
– Attention, memory, and
judgment
– Speech
– Vision
Pathogenesis

■ Significant atherosclerosis
■ Risk factors: hypertension, heart disease, diabetes mellitus,
smoking, hyperlipidemia, family history of vascular disease
■ Other contributing factors: obesity, lack of exercise, and
excessive alcohol consumption
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS: NIH Stroke Scale
DIAGNOSIS

■ MRI or CT Scan
Treatment

■ Blood thinners
■ Cholesterol medications
■ Blood pressure medications
■ Intravenous tissue plasminogen activator

■ Non-drug treatment – low fat, low salt diet


CASE PROPER
PATIENT P.T.
DOB: July 4, 1969
■ Chief Complaint: Left side weakness
■ LSW 6:30 PM (8/9)
■ Ictus 7PM: Patient lying down watching TV, when he had an
onset of left sided weakness of LUE, LLE, inability to lift arm
and subjective loss of sensation with gradual onset of
dysarthria – slurring of speech. Patient tried standing up
however fell on his left side with no head trauma, no LOC
persistence prompted consult via ambulance conduction
■ During transit:
– GCS 15, dysarthic with facial asymmetry, MMT 1/5 LUE,
LLE, 100% sensory, BP 160/110, HR 88, RR 18, O2 Sat
99% at RA
– Transit time: 15 minutes, no changes in sensorium, no
progression of deficits
Patient Medical History

■ HTNx>4 years
■ UBP 140-150
■ No MI/stroke, no allergies, no previous surgery, no PTB
■ Poor healthcare
■ BMI: 34.8
■ Height: 1.88m
■ Weight: 122.7
■ Ideal Body Weight: 79kg
■ No known allergies
Medication History

■ Telmisartan 80mg once a day


■ Nifedipine 60mg once a day
■ Rosuvastatin 5mg ½ tablet once a day
■ Spironolactone 25mg once a day
■ No herbal medicines/supplements
Family History

■ CVD infarct (distant relative)


■ Hypertension
Lifestyle

■ Sedentary lifestyle, occasional alcoholic beverage drinker, 2


PYS until present
At ER

■ GCS (Glasgow Coma Scale) 15


■ BP 150/100
■ HR 90
■ RR 20
■ Temperature 36oC
■ CBC 141
■ Awake, dysarthric, coherent, oriented, with facial asymmetry,
intact gag, good shoulder shrug, MMT 1/5, left extremities, 100%
sensory
■ (+) babinski left, (-) cerebellar symptoms, (-) meningeal signs,
unremarkable systemic PE
At ER

■ PNSS 100mL/hr, given citicoline 1g/IV


■ BAT Called NIHSS, 9
■ Cranial CT negative for hemorrhage, no infarct appraised for RT
PA
■ Bolus RTPA 10mg (0.8mg/kg)
■ BP 180/90, given Nicardipine 1mg Bolus -> 160/70
■ Procedure well tolerated, no bleeding episodes, no
headache/abdominal pain, no changes in sensorium with noted
improvement of speecg and motor function to 3/5 LUE< 4/5LLE,
NIHSS5-> ACSU
At ACSU

O:
■ BP: 173/110-115
■ CR: 80
■ RR: 18-20
■ Temperature: 36.5
■ O2 95% RA
■ Awake, coherent, oriented, nondysarthric, intact extra-ocular
muscles, shallow left NLF, weak left shoulder shrug, intact
gag
At ACSU

A
■ Acute CVD infarct RMCA
■ s/p RTPA 8/9
■ OSA, suspect
Orders:
■ Soft low salt low fat diet with strict aspiration precaution
■ Head bed 30-45 degrees
■ Bed sore precaution
■ No blood extractions within the next 24 hours
■ I&O monitoring
■ WOF: headache, dizziness, progression of symptoms
■ Increase IV to 80ml/hr
■ Give KCL tab 750mg/tablet 1 tablet 3x a day for 6 doses orally for
hypokalemia
■ Hook O2 support at 2lpm via nasal cannula while asleep
Review of Medications

■ Citicoline 1g IV 2x for neuroprotection


■ Atorvastatin 80mg/tablet 1 tablet orally once a day for plaque
stabilization
■ Omeprazole 40mg/tablet pre-breakfast for ulcer prophylaxis
■ Lactulose 3.5mg/5mL 30mg once a day
■ Paracetamol 500mg/tablet 1 tablet every 6 hours for pain
■ KCl 750mg/tablet 3x a day 6 doses for hypokalemia