CASE ON Lt ACUTE MCA

TERRITORY INFARCT AND

WATER VESSEL INFARCT

By,
Umme Habeeba A Pathan
4th Pharm D
Roll no : 29
Bapuji Pharmacy college
Davangere
TYPES OF STROKE
 SUBJECTIVE
• NAME : XYZ
• AGE : 68 years
• GENDER : MALE
• IP NO : IP1911170081
• WARD : MICU
• DOA : 17/11/2019
• DOD : 24/11/2019
• Reason for admission :
1. c/o weakness of right upper limb and right
lower limb since 2 days,
2. not responding to verbal commands,
3. deviation of angle of mouth to left side.
4. Aphasia since 3 days
5. Patient admitted had hyperglycemia and
hyponatermia likely due to hypovolemia
• PATIENT MEDICAL HISTORY:
1. K/C/O TYPE2 DM AND HTN SINCE 3 YEARS
• PATIENT MEDICATION HISTORY : Not mentioned.
 OBJECTIVE
O/E
• BP : 140/90 mm Hg • Icterus : +ve
• PR : 82 bpm • Movement of right
• RR : 20 cpm upper limb : +ve
• CNS : Altered • Facial plasy : +ve
consciousness • Aphasia : +ve
• Sensorium : Drowsy • Pain score : 2
• Spontaneous eye • ECG : sinus rhythm
movement : +ve
LABORATORY INVESTIGATION(18/11/2019)
PARAMETERS OBSERVED VALUE NORMAL RANGE
Hb 15.0 mg/dl 13-18 mg/dl
RBC 5.2 million cells/mm³ 4.5-6.5 million cells/mm³
T.C 19300 cells/mm³ 4000-11000 cells/mm³
ESR 34 mm/hr 0-20mm/hr
Sr. Na 126.8 mmol/L 135-145mmol/L
Sr. K 3.8 mmol/L 3.5-5.0 mmol/L
Sr. Cl 92.5 mmol/L 100-105mmol/L
RBS 354 mg/dl <200mg/dl
Total bilirubin 1.3 mg/dl 0.3-1.2 mg/dl
Direct bilirubin 0.5 mg/dl Upto 0.2 mg/dl
Indirect bilirubin 0.8 mg/dl 0-0.6 mg/dl
A/G ratio 1.56 1.0-1.5
Urea 72.4 mg/dl 10-50 mg/dl
Sr. Cr 1.33mg/dl 0.7-1.2mg/dl
(18/11/2019)
PARAMETERS OBSERVED VALUE NORMAL RANGE
HbA1C 8.3% Upto 6%
Mean blood glucose 191.0mg/dl 100-130 mg/dl
Total cholesterol 212.1mg/dl ≤200mg/dl
Tri G 126.6 mg/dl 35.3-79.5 mg/dl
LDL 135.7mg/dl <100 mg/dl
VLDL 25.3 mg/dl 10-35 mg/dl

CT scan of brain : Scan shows MCA infarct

No Midline Shift
CCA(common carotid artery) thrombus < 56%
• (19/11/2019)
ECHOCARDIOGRAPY REPORT

1. VALVES:
a) Aortic valve : Sclerotic.

2. DOPPLER DATA:
b) Mitral : MR – Mild
c) Aortic : peak gradient - 10 mm Hg
d) Tricuspid : TR Trivial PASP- 28 mm Hg
e) Pulmonary : peak gradient- 3mm Hg
f) LVOT : normal
g) Vegetation/Thrombus : normal
h) Pericardium : normal
 DIAGNOSIS
• BASED ON SUBJECTIVE AND OBJECTIVE
EVIDENCES PATIENT IS DIAGNOSED WITH

1. LEFT ACUTE MCA TERRITORY INFARCT WITH

WATER VESSEL INFARCT.
2. MILD MR WITH SCLEROTIC AORTIC VALVE.

FINAL DIAGNOSIS : ISCHEMIC STROKE

 GOALS OF THERAPY
• To relieve signs and symptoms.
• To improve quality of life of patient.
• To stabilize the patient.
• The immediate goal is to re-establish adequate
blood flow in his diseased cerebral vessels.
• Longer-range objectives are to prevent reocclusion,
decrease the risk of future symptomatic TIAs, and
ultimately, prevent a cerebral infarction.
• To restore the lost facial muscle and limb function by
physiotherapy.
 PLAN (18/11/2019)
IV LINE 1 IVF NS – 100 ml Every 1 hour 7am – 10 am (18/11/19)
IV LINE 2 3% NaCl – 10 ml Every 1 hour 9am – 6 am ( 19/11/19)
IV LINE 3 IV DNS – 50 ml Every 1 hour 9am – 6 am ( 19/11/19)

Sl no DRUG GENERIC NAME DOSE FREQUENCY

1 Inj Ondem Ondansetron 4mg 1-0-1
2 Inj Mannitol Mannitol 100mg 1-1-1-1
4 Inj Edavit Edaravone 1 amp in 100ml NS over 1-0-1
30 min
5 Inj cerehenz Cerebroprotien 1amp in 100ml NS over 1-0-1
hydrosylate 30 min
6 Syp oral glycerol Glycerol 30ml 1-1-1
7 Tab Ecosprin Aspirin 75 mg 0-0-1
8 Tab Clopidogrel Clopidogrel 75 mg 0-0-1
9 Tab Avas 80 atorvastatin 80 mg 0-0-1
 10 Inj Piptaz Piperacillin + 4.5 g 1-0-1
Tazobactum
11 Inj Xone Ceftriaxone 1g 1-0-1

• Hepatitis B – Non Reactive

• HIV Rapid – Non Reactive
• T3 – 0.67ng/dl ( 0.4 - 1.8 ng/dl)
• T4 – 8.79 mcg/dl (5.0 – 10.7 mcg/dl)
• TSH – 2.11 IU/ml (0.5 – 8.9 IU/ml)
• Catheter associated UTI : checked
• Advise echocardiography and dietician
department review.
DAY 2 (19/11/19)
O/E
• Conscious, obeying commands, vitals stable
• BP : 140/90 mm Hg
• Na⁺ : 131.2 mmol/L
• K⁺ : 3.8 mmol/L
• Cl⁻ : 96.7 mmol/L
• Consider increase calorie intake, RT feed every 4
hour (700 calorie).
• Plan to decrease or stop fluid by evening (2L/day).
• Echocardiography report show sclerotic aortic
valve and mild MR.
• Catheter associated UTI : checked
IV LINE 1 IVF NS – 75 ml Every 1 hour 7am – 10 am
30ml 11 am – 6 am
IV LINE 2 3% NaCl – 10 ml Every 1 hour 9am – 6 am
IV LINE 3 IV DNS – 40 ml Every 1 hour 11am – 6 am

Urea : 50.4 mg/dl Rx

CST
GRBS : 140 mg/dl Stop
Inj Xone
DAY 3 ( 20/11/19)
IV LINE 1 IVF NS – 75 ml Every 1 hour 7am – 11 am
50ml 12 pm – 10pm
IV LINE 2 3% NaCl – 10 ml Every 1 hour 7am – 10 pm
IV LINE 3 IV DNS + Actrapid + Every 1 hour 7am – 11 am (stopped)
10 mg KCl @ 40
ml/hr

O/E Cl⁻ : 105.7 mmol/L

BP : 150/90 mm Hg Rx
Aphasia +ve CST
Facial palsy +ve adjust mannitol 1-1-1
Na⁺ : 136.4 mmol/L Patient advised to shift to male
K⁺ : 3.3 mmol/L ward tomorrow

Case seen by endocrinology and reviewed , clinically

improved and no fresh complaints
DAY 4 ( 21/11/19)
• Patient shifted to male general ward.
• O/E; BP : 140/80 mm Hg
• Advise Physiotherapy
• RT feed 100ml every 4 hourly.
• Continue same therapy
• IVF NS @ 75ml/hr till 10pm and stop it.
• IVF 3% NaCl @ 10ml/hr till 10pm and stop it.
DAY 5 ( 22/11/19)
• O/E
• BP : 130/90 mm Hg
• CNS : conscious and oriented.
• RT feed 3rd hourly 100ml
• IVF can be stopped.
• Inj Actrapid 6–6–6–5
(15 min before food) 7am-11am-5pm-10pm

• Inj Lantus 79am

– 0 – 0 – 610pm

• Physiotherapy continued and CST.

DAY 6 ( 23/11/19)
O/E BP : 130/90 mm Hg
PARAMETERS OBSERVED VALUE NORMAL RANGE
Hb 14.8 mg/dl 13-18 mg/dl
RBC 5.1 million cells/mm³ 4.5-6.5 million cells/mm³
T.C 13100 cells/mm³ 4000-11000 cells/mm³
PCV 44.4% 47± 7%
RDW 13.3 11-15
Platelet Count 3.03 lakh cells 1.5 – 4.5 lakh cells

CNS : conscious and oriented

Obey commands Rx
GRBS monitoring : 7am 11 am 5 pm 9pm CST
Inj actrapid 5 – 4 – 4 – 4 Physiotherapy continued….
Inj lantus 6 – 0 – 0 – 5 Patient is advised on discharge
• Day 7 ( 24/11/19)
• BP : 130/90 mm Hg

PARAMETERS OBSERVED VALUE NORMAL VALUE

TC 11000 cells/mm³ 4000-11000 cells/mm³
FBS 130 mg/dl <100 mg/dl
RBS 195 mg/dl <200 mg/dl
Total cholesterol 200mg/dl ≤200mg/dl
Urea 45mg/dl 20-50 mg/dl
Total cholesterol 190.1mg/dl ≤200mg/dl
Tri G 96.6 mg/dl 35.3-79.5 mg/dl
LDL 95.7mg/dl <100 mg/dl
 DISCHARGE MEDICATION
SL DRUG GENERIC NAME DOSE FREQUENCY NO OF DAYS
NO
1 Tab Ecosprin Aspirin 75 mg 0-0-1 10
2 Tab Clopidogrel Clopidogrel 75 mg 0-0-1 10
3 Tab Colihenz Citocoline+ 500mg+ 1-0-0 30
Piracetam 400 mg
4 Tab Avas 80 Atorvastatin 80 mg 0-0-1 10
5 Inj. H. mixtard Inj insulin 20-0-10 1-0-1 15

REVIEW AFTER 10 DAYS

 GOALS ACHIEVED
• Patient’s life became better.
• Patient’s CNS became conscious and oriented.
• Patient started to obey commands.
 MONITORING PARAMETERS
• Disease monitoring :
1. Risk of bleeding (hemorrhage), infection, blood pressure, radial artery pulse
monitoring.
2. Stroke survivors are at increased risk of recurrent ischemic events, including
recurrent stroke and myocardial infarction (MI). Particularly in the first hours and
days after a transient ischemic attack (TIA) or stroke, risk of recurrence is high.
Recurrent strokes lead to dementia more often and have higher case fatality than
first strokes
• Drug monitoring :
1. Aspirin, Clopidogrel – antiplatelet have high risk of bleeding.
2. Ondem – monitor electrolytes
3. Mannitol – discontinue if renal, cardiac or pulmonary status worsens or CNS toxicity
develops.
4. Cerebroprotien hydrolysate – monitor protein levels
5. Edaravone – monitor hypersensitive reaction.
6. Glycerol -
7. Regular insulin and insulin glargine : monitor blood glucose level.
 PHARMACIST ACTIVITY
• Drug interaction:
Moderate drug interactions were found –
1. Aspirin <> Clopidogrel – unusual bleeding may occur.
Carefully monitor the risk of bleeding.
2. Atorvastatin <> Clopidogrel – combination reduces the
efficacy of clopidogrel . Dosage adjustment is necessary.
3. Aspirin <> insulin glargine
4. Aspirin <> insulin regular
These both interaction can cause risk of hypoglycemia but
patient is monitored with RT feed.
• INTERVENTIONS:
 Inj ondem is given without indication. It may
lead to serotonin syndrome.
 No hepatoprotectancts were given for
abnormal LFT. Drug like silymarin 560 mg OD
can be given.
 No anti seizures were prescribed when patients
eye movement was positive. Drug of choice for
post stroke seizures is Lorazepam 4mg OD.
 PATIENT COUNSELLING
• ABOUT DISEASE :
1. Call 108 in emergency situation.
2. Take your medicine as directed.
3. Go to stroke rehabilitation(rehab) if directed.
4. Wear pressure stockings as directed.
5. Control your blood sugar level if you have
hyperglycemia or diabetes.
6. Mirror therapy at rehabilitation.
• ABOUT DRUGS :
1. The drugs patient is taking has high risk of bleeding so avoid
cuts and wounds.
2. Instruct patient about the use of insulin pen.
• Life style modification.
1. Exercise as directed not more or less.
2. Make your home safe. Remove anything you might trip over.
3. Eat a variety of healthy foods. Healthy foods include whole-
grain breads, low-fat dairy products, beans, lean meats, and
fish. Eat at least 5 servings of fruits and vegetables each day.
Choose foods that are low in fat, cholesterol, salt, and sugar.
Eat foods that are high in potassium, such as potatoes and
bananas. A dietitian can help you create healthy meal plan.
4. Maintain a healthy weight. Ask your healthcare provider
how much you should weigh. Ask him or her to help you
create a weight loss plan if you are overweight. He or she
can help you create small goals if you have a lot of weight to
lose