Ischemic Stroke

A Case Study

Presented to the

School of Nursing

Northern Luzon Adventist College

In Partial Fulfillment of

The requirements for the Course

RLE

By:

Cerezo, April

Degsi, Nobeth A.

Gagarin, Mylene

Salvador, Marjurytt
I. Introduction- insights about the disease
An ischemic stroke, formerly referred to as a cerebrovascular accident or "brain attack," is a sudden
loss of function resulting from disruption of the blood supply to a part of the brain. The term brain attack
has been used to suggest to health care practitioners and the public that a stroke is an urgent health care
issue similar to a heart attack. The only U.S. Food and Drug Administration (FDA)-approved thrombolytic
therapy has a treatment window of 3 hours after the onset of a stroke, and scientific statements have
endorsed its expanded use for up to 4.5 hours (Del Zoppo, Saver, Jauch, et al., 2009; Powers, Rabinstein,
Ackerson, et al., 2019). Although the time frame for treatment has expanded, urgency is needed on the part
of the public and health care practitioners for rapid transport of the patient to a hospital for assessment and
administration of the medication.

Prevalence:
Stroke is the second leading cause of both disability and death worldwide, with the highest
burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new
incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about
10%-20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT
globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide
in 2016. This highlights the large gap among eligible patients and the low utilization rates of these
advances across the globe. Multiple global initiatives are underway to investigate interventions to
improve systems of care and bridge this gap (Saini, Guada, & Yavagal, 2021).

A. Patient's profile
Client’s rights:
Age: 78 years old
Sex: Female
Status: Married
Nationality: Filipino
Religion: Roman Catholic
Address: Urbiztondo, Pangasinan
Attending Physician: K. N. Decena, M.D.
Date and time of admission: March 30, 2023 @4:45pm
Admitting diagnosis: To consider cerebrovascular disease infarct, left main coronary artery territory in
hypertensive urgency HIHSS 17
Medical diagnosis: Ischemic stroke

General data
Patient X is 78 years old, female. She is a filipino citizen who lives in Urbiztondo, Pangasinan.
She is married and a housewife. She is living in a rural area and patient x is not part of any indigenous
group.
She was brought to the hospital last March 30, 2023 by her daughter because she had been
experiencing right side body weakness with difficulty of speech. It was stated that the patient has already
had multiple hospitalizations in the past, commonly with hypertension. Vital signs are taken as follows;
temperature of 36.8 degrees celsius, heart rate of 88 beats per minute, respiratory rate of 18 counts per
minute, blood pressure of 150/100 mmHg, and lastly, oxygen saturation of 96%.
B. Present complaint:
Right sided body weakness

C. Past/family/social medical history

Patient’s past medical hx
Hypertension – noncompliant, the patient doesn’t take her maintenance.

Family hx
Mother: Hypertension

Occupation and environment

None

Drug therapy
The patient was given medication for hypertension such as Losartan.

D. Developmental task

Erik Erikson’s Psychosocial Theory (late adulthood)

Integrity vs. Despair occurring in late adulthood
Integrity vs. despair involves a retrospective look back and life and either feeling satisfied that life was
well-lived (integrity) or regretting choices and missed opportunities (despair). In order to understand this
stage, it is important to first understand what Erikson meant by integrity and despair.
The patient is happy and contented with what life she has. The patient is aware and she accepts that life
has an end. But when the patient was hospitalized, she regrets not complying with her medication.

Psychosexual Theory by Sigmund Freud

Genital Stage
The goal of this stage is to establish a balance between the various life areas. Unlike many of the earlier
stages of development, Freud believed that the ego and superego were fully formed and functioning at this
point.
The patient was able to balance her emotions and relationship with her family especially to her husband.

Cognitive Theory of Jean Piaget

The Formal Operational Stage
The final stage of Piaget's theory involves an increase in logic, the ability to use deductive reasoning,
and an understanding of abstract ideas. At this point, adolescents and young adults become capable of
seeing multiple potential solutions to problems and think more scientifically about the world around them.
The patient was able to solve any problem or conflict that comes into her life, she developed the capacity
to think about abstract concepts and to assess hypotheses using logical reasoning.

Lawrence Kohlberg’s Moral Development Theory

Postconventional Morality
At this level of moral development, people develop an understanding of abstract principles of
morality. The two stages at this level are:
Stage 5 (Social Contract and Individual Rights): The ideas of a social contract and individual rights
cause people in the next stage to begin to account for the differing values, opinions, and beliefs of other
people. Rules of law are important for maintaining a society, but members of the society should agree upon
these standards.
Stage 6 (Universal Principles): Kohlberg’s final level of moral reasoning is based on universal ethical
principles and abstract reasoning. At this stage, people follow these internalized principles of justice, even
if they conflict with laws and rules.
Morality is important for the patient. She respects and values the opinions and beliefs of other people.
She abides by the law because she wants to have an organized society.

E. Physical assessment
a. Health Maintenance-Perception Pattern
Prior to hospitalization: The patient doesn’t have any vices like smoking and drinking alcohol.
She also reported that she is not taking any therapeutic drugs.
During hospitalization: The patient was diagnosed to have ischemic stroke. She was given
medications such as Losartan, Linagliptin, and Clindamycin.

b. Nutritional-Metabolic Pattern
Prior to hospitalization: The patient occasionally consumes vegetables, fruits, and fish, but she
consumes meat the majority of the time. She enjoys her typical breakfast of adobong chicken and
fish. She also eats her favorite recipes with a cup of rice for lunch and dinner. She consumes at
least 7 glasses of water per day. She also mentioned that she did not have any food allergies.
During hospitalization: The patient has lost her appetite and has difficulty eating. That's why she
only eats a tiny amount of food due to her current state.

c. Elimination Pattern
Before hospitalization: The patient mentioned that she did not have any troubles in defecating,
urinating, or perspiring. She defecates once a day usually in the morning.
During hospitalization: She was inserted with IFC and changes diapers 3 times a day. The patient
has a urine output of 1000 mL to 1500 mL per shift.

d. Activity and Exercises

Before hospitalization: The patient exercised daily like walking.
During hospitalization: She experienced weakness and lying on bed. She also needs assistance in
doing simple activities like eating, sitting and standing up. Her muscle movements decreased and
has limited range of motion.

e. Sleep/Rest Pattern

Prior to hospitalization: She can sleep at least 7-9 hours in a day.

During hospitalization: She developed an irregular sleeping pattern due to her present condition.

f. Cognitive- Perceptual Pattern

Before hospitalization: Her hearing and visual acuity are good. Furthermore, she reacts to stimuli
physically as well as verbally.
During hospitalization: Although the patient is weak she was still responsive and
cooperative. Despite her physical limitations, the patients was able to respond and comply.

g. Role-Relationship Pattern
Before hospitalization: She lives with her husband, well supported and loved by her family.
During hospitalization her daughter stays and takes care of her.
 h. Sexuality-Reproductive Pattern
The patient does not have any sexual activities. She has no history of sexually transmitted disease
or any disease affecting her genitals.

i. Coping- Stress Tolerance/Self-Perception/Self Concept

Before hospitalization: The patient remains optimistic despite her situation, she still believes that
she will get better soon and has a strong faith in God, especially for her healing. She also
perceived herself as a good mother. However, she’s a bit disappointed with herself due to her
present condition.
During hospitalization: During her stay in the hospital she has a strong faith that she would get
better soon with the help of the doctors and nurses and most especially with the help of God. She
also sleeps and rests when she feels tired and weak.

j. Value- Belief Pattern

She is a Roman Catholic and willing to be offered a prayer every end of the shift. Faith in God
makes her motivated to fight for her disease.

II. Anatomy and physiology

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 brain does not store nutrients and requires a constant supply of oxygen. These needs are met
through cerebral circulation; the brain receives approximately 15% of the cardiac output, or 750 mL per
minute of blood flow.
Brain circulation is unique in several aspects. First, arterial and venous vessels are not parallel as
in other organs in the body; this is due in part to the role the venous system plays in CSF absorption.
Second, the brain has collateral circulation through the circle of Willis, allowing blood flow to be
redirected on demand. Third, the blood vessels in the brain have two rather than three layers, which may
make them more prone to rupture when weakened or under pressure.

Cerebrovascular system anatomy and physiology

1. Middle cerebral artery

Middle cerebral artery. is the largest branch and the second terminal branch of the internal carotid
artery. It lodges in the lateral sulcus between the frontal and temporal lobes and is part of the circle of
Willis within the brain,and it is the most common pathologically affected blood vessel in the brain. The
MCA is divided into four main surgical segments, denominated M1 to M4.
- The M1 segment extends from the ending of the internal carotid artery, perforating the
brain up to its division.
- The M2 segment bifurcates or occasionally trifurcates. It travels laterally to the Sylvian
fissure, and its branches end in the cerebral cortex.
- The M3 segment travels externally through the insula into the cortex. Finally,
- The M4 segments are thin and extend from the Sylvian fissure to the cortex
It supplies the greater part of the lateral cerebral surface (including the main motor and sensory
areas) as well as giving the striate arteries which supply deep structures including the internal capsule.
An embolism is transported through the blood vessels until it is lodged in the MCA. The arterial
occlusion impedes perfusion of oxygenated blood to the brain parenchyma, resulting in an ischemic
stroke causing cerebral edema and brain parenchyma tissue necrosis. A stroke of the MCA is denoted as
middle artery syndrome. presents with:
 - Contralateral sensory loss of the legs, arms, and lower two-thirds of the face due to tissue
necrosis of the primary somatosensory cortex.
- Contralateral paralysis of the arms, legs, and face may be observed due to necrosis of the
primary motor cortex, which is observed clinically as muscle weakness, spasticity,
hyperreflexia, and resistance to movement (upper motor neuron signs).
- Ipsilateral eye deviation is observed due to frontal cortex Brodmann area 8 becoming
ischemic, impairing planning of eye movement, symptoms that are exacerbated by
contralateral homonymous hemianopsia. A dominant, most commonly left-sided,
hemisphere stroke results in Broca aphasia if the superior division of the MCA is
affected. In contrast, Wernicke’s or conduction aphasia may be seen if the inferior
division of the MCA is affected. A non-dominant, most commonly right-sided,
hemisphere stroke results in hemineglect syndrome, presenting with anosognosia,
apraxia, and hemispatial neglect.

2. Anterior cerebral artery

The anterior cerebral artery (ACA) arises from the internal carotid, at the medial extremity of the
lateral cerebral fissure. It passes forward and medialward across the anterior perforated substance, above
the optic nerve, to the commencement of longitudinal fissure. Is one of a pair of arteries on the brain that
supplies oxygenated blood to most midline portions of the frontal lobes and superior medial parietal
lobes.
The ACA has five segments. A1 originates from the internal carotid artery and extends to the
anterior communicating artery. A2 extends from the anterior communicating artery to the bifurcation
forming the pericallosal and callosomarginal arteries. A3 is one of the main terminal branches of the
ACA, which extends posteriorly to form the internal parietal arteries and the precuneal artery. A4 and A5
are the smallest branches and are known as callosal arteries.
ACA supplies the frontal, pre-frontal and supplementary motor cortex, as well as parts of the
primary motor and primary sensory cortex.
ACA infarcts are rare because of the collateral circulation provided by the anterior
communicating artery. ACA infarct can present as contralateral hemiparesis with loss of sensibility in the
foot and lower extremity, sometimes with urinary incontinence. This is due to the involvement of the
medial paracentral gyrus. If the lesion is very proximal, it is possible that there may be cognitive
impairment due to lesions in the prefrontal cortex.

3. Anterior communicating artery

The anterior communicating artery (often abbreviated ACom or AComm) arises from the anterior
cerebral artery and acts as an anastomosis between the left and right anterior cerebral circulation.
Approximately 4 mm in length, it demarcates the junction between the A1 and A2 segments of the
anterior cerebral artery.
Besides forming the anastomotic channel between the anterior cerebral arteries, the functions of
the anterior communicating artery are also to contribute to the blood supply of certain parts of the brain.
Via its anteromedial central branches, this artery supplies parts of the optic chiasma, lamina terminalis,
preoptic and supraoptic areas of the hypothalamus, parolfactory areas of the frontal cortex, anterior
columns of fornix and the cingulate gyrus.
Anterior communicating artery aneurysm can cause visual symptoms by compressing the optic
nerve or direct rupture to the optic nerve with focal hematoma formation.

4. Internal carotid artery

It is the terminal branch of the common carotid artery, it is larger than the other terminal branch
(the external carotid artery). There are seven segments according to Bouthillier classification:
- C1/ Cervical segmen
 - C2/ Petros (horizontal) segment
- C3/ Lacerum segment
- C4/ Cavernous segment
- C5/ Clinoid segment
- C6/ Ophthalmic (Supra clinoid) segment
- C7/ Communicating segment
The internal carotid artery, being one of the most clinically relevant and vital arteries, supplies
oxygenated blood to crucial structures such as the brain and eyes.
The internal carotid arteries are of vital importance for oxygenated blood supply to the brain, and
so they are of major importance in clinical evaluation. They are susceptible to atherosclerosis, which can
cause stenosis and embolization of plaque distally towards the brain. Particular pathologies in which the
internal carotid artery should undergo evaluation include, but are not limited to, stroke, transient ischemic
attack, penetrating neck trauma, and hypovolemic shock.

5. Posterior cerebral artery

The left and right posterior cerebral artery arises from the bifurcation of the basilar artery, which
occurs at the superior border of the pons, posterior to the dorsum sellae. From there, the posterior cerebral
artery continues laterally along the superior border of the pons. It courses parallely to the superior
cerebellar artery, separated from it by the oculomotor nerve (CN III). Upon reaching the lateral border of
the pons, the posterior cerebral artery curves around the cerebral peduncle to reach the medial surface of
the cerebral hemispheres, where it supplies the temporal and occipital lobes.
The PCA supplies blood to the posterior parietal cortex, occipital lobe and inferior temporal lobe.
There are several branches of this artery that supply the midbrain, thalamus, subthalamus, posterior
internal capsule, optic radiation and cerebral peduncle.
General anatomy textbooks divide the posterior cerebral artery into three segments; P1, P2 and
P3. However, the latest neuroanatomical classification which is used in neurosurgical practice divides the
artery into the following four segments:
- P1: extends from the basilar bifurcation to the anastomosis with the posterior
communicating artery
- P2: extends from the anastomosis with the posterior communicating artery to the part of
the artery that lies in the perimesencephalic cistern on the posterior border of the lateral
aspect of the midbrain.
- P3: extends from the posterior border of the lateral aspect of the midbrain to the origin of
parieto-occipital and the calcarine arteries.
- P4: represent the terminal branches found in the calcarine fissure.
Posterior circulation strokes involve infarction occurring in the vertebrobasilar arterial system,
which in contrast to anterior circulation strokes, can be challenging to diagnose and manage due to
variable anatomy and nonspecific presenting symptoms. The most common symptoms are nonspecific
and include headache and visual impairment. The specific visual defect or dysfunction depends on the
size and location of the infarct.

6. Posterior communicating artery

The posterior communicating artery (PComm) is a branch of the internal carotid artery that
participates in the cerebral arterial circle of Willis. The posterior communicating artery connects the
internal carotid with the posterior cerebral arteries, thus connecting the anterior and posterior cerebral
circulations.
The main function of the posterior communicating artery is to provide an alternative route to the
brain blood supply in case there is a blockage of the internal carotid or vertebral arteries. Besides this, the
posterior communicating artery contributes to the blood supply of the internal capsule, parts of the
diencephalon and third ventricle via its posterolateral central branches.
 A stroke occurs when there is an interruption of blood flow in an artery. This blockage keeps
blood from reaching its destination in the brain, resulting in a loss of function in the affected region.
Strokes can happen when a blood clot gets lodged in an artery, becomes blocked from disease, or if a
blood vessel bleeds.

7. Basilar artery
The basilar artery is a midline structure formed from the confluence of the vertebral arteries.
Terminally, the basilar artery branches to establish the right and left posterior cerebral arteries. Along its
course, the basilar artery gives off several branches.
The basilar artery contributes to the posterior component of the circle of Willis and supplies the
contents of the posterior cranial fossa. It arises from the confluence of two vertebral arteries at the
medullo-pontine junction, to ascend through the basilar sulcus on the ventral aspect of the pons. It
provides arterial supply to the brainstem, cerebellum, and contributes to the posterior circulation through
the posterior cerebral arteries.
Basilar artery thrombosis refers to a cerebrovascular accident or stroke due to occlusion of the
basilar artery by a thrombus. The risk factors are similar to those in other occlusive cerebrovascular
accidents. Implicated risks include atherosclerosis promoting factors like hypertension, hyperlipidemia,
smoking, obesity, diabetes, and coronary artery disease. Clinical manifestations often correspond to the
level and degree of occlusion. Symptoms can include hemiparesis, quadriparesis, ataxia, dysphonia,
dysarthria, oculomotor palsy, and abducens palsy. These may present as groups of signs and symptoms
recognized as distinct clinical syndromes:
- "Top-of-the-basilar" syndrome involves occlusion in the rostral part of the basilar artery,
resulting in ischemia affecting the upper brainstem and the thalamus. Clinical
manifestations include behavioral changes, hallucinations, somnolence, visual changes,
and oculomotor disturbances.
- Locked-in syndrome involves occlusion at the proximal and middle part of the basilar
artery, sparing the tegmentum of the pons. The patient is thus conscious and oculomotor
function is preserved, but other voluntary muscles of the body are affected. These
patients cannot move or talk, but consciousness is evident because of vertical eye
movement, which is an oculomotor nerve function.
- Pontine warning syndrome is a basilar artery atherosclerotic disease characterized by
motor and speech disturbances that occur in a waxing and waning manner. These patients
typically experience recurrent on-and-off attacks of hemiparesis and dysarthria. This
syndrome is indicative of an imminent basilar artery branch occlusion with infarction of
the supplied region.

8. Vertebral artery
The vertebral artery is a major artery in the neck. It branches from the subclavian artery, where it
arises from the posterosuperior portion of the subclavian artery. It ascends through the foramina of the
transverse processes of the cervical vertebrae, usually starting at C6 but entering as high as C4. It winds
behind the superior articular process of the atlas. It enters the cranium through the foramen magnum
where it unites with the opposite vertebral artery to form the basilar artery (at the lower border of the
pons). The vertebral artery can be divided into four divisions:
- The first division runs posterocranial between the longus colli and the scalenus anterior.
The first division is also called the ‘pre-foraminal division’.
- The second division runs cranial through the foramina in the cervical transverse processes
of the cervical vertebrae C2. The second division is also called the foraminal division.
- The third division is defined as the part that rises from C2. It rises from the latter foramen
on the medial side of the rectus capitis lateralis, and curves behind the superior articular
process of the atlas. Then, it lies in the groove on the upper surface of the posterior arch
 of the atlas, and enters the vertebral canal by passing beneath the posterior
atlantoöccipital membrane.
- The fourth part pierces the dura mater and inclines medial to the front of the medulla
oblongata.
It supplies 20% of blood to the brain (mainly hindbrain) along with the internal carotid artery (80%).
In older individuals, atherosclerotic changes and other vascular risk factors (e.g. hypertension, high
cholesterol, smoking, diabetes) may contribute to altered blood flow in the arteries. The vertebral and
carotid arteries are stressed primarily by rotation, extension and traction, but other movements may also
stretch the artery. As little as 20% of rotation and extension have been shown to significantly decrease
vertebral artery blood flow.

9. Anterior spinal artery

The anterior spinal artery is a major artery providing nutrient-rich blood supply to the entire
spinal cord section except for the dorsal columns. This artery runs along the entire length of the spinal
cord anastomosing with other arteries.
A stroke of the anterior spinal artery results in loss of blood supply to a major portion of the
spinal cord. This is known as anterior spinal artery syndrome, which is characterized by loss of motor
function below the level of injury, loss of sensations carried by the anterior columns of the spinal cord
(pain and temperature) while not affecting proprioception carried by the dorsal columns. The blood
supply does not affect this dorsal portion of the spinal cord.
In adolescents, adults, and the elderly, the criteria for spinal cord injury is more broadened. There
is a further distinction between the 2 genders. Adolescents experience spinal cord injury primarily
through accidental means. Many of these patients experience back pain. One cause is the slipped disk or
herniated disk. The result of wear and tear may cause this. As people age, the spinal discs lose their
elasticity. They can lose their gel-like fluid and become brittle and cracked. In adults, it is due to lifting a
heavy object or accident. These discs, also known as the nucleus pulposus, are between 2 vertebrae. Once
slipped, the disc impinges on the nearby nerve, irritating it. The symptoms experienced by these patients
can be sudden or severe shooting pain.

III. Pathophysiology
Concise and in-depth discussion
A. Illustration/Diagram of Pathophysiology
1. Etiology
The second most common cause of mortality worldwide is stroke. Each year, it
affects 13.7 million people and kills about 5.5 million. The prevalence of ischemic
infarctions, which account for about 87% of strokes, grew significantly between 1990 and
2016, which is attributed to lower mortality and better clinical interventions. The majority
of strokes are caused by primary (first-time) hemorrhages, with secondary (second-time)
hemorrhages accounting for between 10% and 25%. Over the period 1990–2016, the
incidence of stroke increased in low- and middle-income countries, while it decreased by
42% in high-income nations. The age of those affected, their sex, and their location have
all grown over time, according to the Global Burden of Disease Study (GBD), despite the
fact that the prevalence of stroke has declined.
Age-specific stroke:Age-related increases in stroke frequency double after age 55.
However, a worrisome trend shows that between 1990 and 2016, the percentage of stroke
cases worldwide among adults aged 20 to 54 rose from 12.9% to 18.6%. Nevertheless,
throughout the same time period, age-standardized attributable death rates dropped by
36.2%. China has the highest recorded rate of stroke incidence, affecting 331-378 people
per 100,000 life years. Eastern Europe has the second-highest rate (181-218 per 100,000
life years), whereas Latin America has the lowest rate (85-100 per 100,000 life years).
Gender-specific stroke: Age has an impact on both the frequency of stroke in men and
women. Women are more likely to experience it at younger ages, but men's frequency
somewhat rises with age. Pregnancy-related variables, such as preeclampsia, the use of
contraceptives and hormonal therapy, migraine with aura, and hormone therapy all
increase the risk of stroke in women. In women over 75, atrial fibrillation 20% increases
the risk of stroke. Women are also more likely to die from a stroke. Women experience
strokes at higher rates than males, which is related to their longer life expectancies.
Women's hesitation to seek medical attention for persistent symptoms is also a serious
worry. The most frequent causes of stroke in men include myocardial infarction,
excessive alcohol use, smoking, and vascular conditions.
Geographic and racial variation: 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. Insufficient physical activity, poor
food habits and nicotine and alcohol consumption were considered added risks.
Differences in exposure to environmental pollutants, such as lead and cadmium, also
influenced stroke incidences across regions.
Socioeconomic variation: Stroke and socioeconomic level are strongly inversely
correlated, which can be attributed to low-income populations' insufficient access to post-
stroke care and subpar hospital infrastructure. According to a case study done in the US,
those who are well off have access to more effective stroke therapy alternatives. Low
income and no health insurance were connected in a study conducted in China to the
prevention of secondary stroke attacks. There was no difference in the administration of
thrombolysis, occupational therapy, physiotherapy, or stroke care for secondary attack
according to socioeconomic status, according to research conducted in Austria. Level of
education was connected with the uptake of therapies such as echocardiography and
speech therapy. Similar to this, no matter the patients' financial situation, fundamental
medical services like thrombolysis were offered in the Scottish healthcare system.

The most common cause of Ischemic stroke can be classified as:

Large-vessel atherosclerosis
Large-vessel atherosclerosis can affect intracranial or extracranial arteries.
Atheromas, particularly if ulcerated, predispose to thrombi. Atheromas can occur in any
major cerebral artery and are common at areas of turbulent flow, particularly at the
carotid bifurcation. Partial or complete thrombotic occlusion occurs most often at the
main trunk of the middle cerebral artery and its branches but is also common in the large
arteries at the base of the brain, in deep perforating arteries, and in small cortical
branches. The basilar artery and the segment of the internal carotid artery between the
cavernous sinus and supraclinoid process are often occluded.

Cardioembolism
Emboli may lodge anywhere in the cerebral arterial tree.
Emboli may originate as cardiac thrombi, especially in Atrial fibrillation, Rheumatic
heart disease (usually mitral stenosis), Post–myocardial infarction, Vegetations on heart
valves in bacterial or marantic endocarditis, Prosthetic heart valves and Mechanical
circulatory assist devices (eg, left ventricular assist device, or LVAD).
Other sources include clots that form after open-heart surgery and atheromas in neck
arteries or in the aortic arch. Rarely, emboli consist of fat (from fractured long bones), air
(in decompression sickness), or venous clots that pass from the right to the left side of the
heart through a patent foramen ovale with shunt (paradoxical emboli). Emboli may
dislodge spontaneously or after invasive cardiovascular procedures (eg, catheterization).
Rarely, thrombosis of the subclavian artery results in embolic stroke in the vertebral
artery or its branches.

Lacunar infarcts
Ischemic stroke can also result from lacunar infarcts. These small (≤ 1.5 cm) infarcts
result from non atherothrombotic obstruction of small, perforating arteries that supply
deep cortical structures; the usual cause is lipohyalinosis (degeneration of the media of
small arteries and replacement by lipids and collagen). Whether emboli causes lacunar
infarcts is controversial.
Lacunar infarcts tend to occur in older patients with diabetes or poorly controlled
hypertension.
Other causes of stroke include vascular inflammation secondary to disorders such as
acute or chronic meningitis, vasculitic disorders, and syphilis; dissection of intracranial
arteries or the aorta; hypercoagulability disorders (eg, antiphospholipid syndrome,
hyperhomocysteinemia); hyperviscosity disorders (eg, polycythemia, thrombocytosis,
hemoglobinopathies, plasma cell disorders); and rare disorders (eg, fibromuscular
dysplasia, moyamoya disease, Binswanger disease).

In children, sickle cell disease is a common cause of ischemic stroke.

Any factor that impairs systemic perfusion (eg, carbon monoxide toxicity, severe anemia
or hypoxia, polycythemia, hypotension) increases risk of all types of ischemic strokes. A
stroke may occur along the borders between territories of arteries (watershed areas); in
such areas, blood supply is normally low, particularly if patients have hypotension and/or
if major cerebral arteries are stenotic.
Less commonly, ischemic stroke results from vasospasm (eg, during migraine, after
subarachnoid hemorrhage, after use of sympathomimetic drugs such as cocaine or
amphetamines) or venous sinus thrombosis (eg, during intracranial infection,
postoperatively, peripartum, secondary to a hypercoagulability disorder).
2. Systems and processes involved
Stroke is a type of cardiovascular disease. It affects the arteries leading to and within the
brain. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain
is either blocked by a clot or bursts. When that happens, part of the brain cannot get the
blood (and oxygen) it needs, so it starts to die.
When part of the brain dies from lack of blood flow, the part of the body it controls is
affected. Strokes can cause paralysis, affect language and vision, and cause other
problems. Treatments are available to minimize the potentially devastating effects of
stroke, but to receive them, one must recognize the warning signs and act quickly.
3. Manifestations
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. 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, 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

IV. Diagnostic tests

CT Scan
Interpretation:
• Acute infarct, left capsuloganglionic region and left high frontal lobe
• Chronic lacunar infarcts, right capsuloganglionic region and bilateral thalami
• Microvascular ischemic changes, gliosis, and/or areas of demyelination
• Cerebral-cerebellar atrophy
• Atherosclerotic vessel disease
• Polysinusitis

X-RAY
Interpretation:
• Probable cardiomegaly
• Atherosclerotic aorta
• Degenerative osseous changes

Parameter Normal Range Patient

Hemoglobin 120 - 160 133 g/L

Total WBC 4.0 - 10.0 12.3 /L

Neutrophils 55.0 - 65.0 70%

Lymphocytes 25.0 - 35.0 25%

Eosinophils 2.0 - 4.0 2%

Monocytes 3.0 - 6.0 3%

Basophils 0.0 - 1.0 00%

V. NCP
VI. Drug study
Drug study #1
• Generic name: Losartan

• Brand name: Cozaar

• Classification: Angiotensin II receptor antagonists

• Indication: To treat hypertension. And reduce the risk of stroke in patients with hypertension

• Doses/route/frequency: 50g 1-tab oral OD

• Contraindications: It is contraindicated in hypersensitivity to losartan or any of its components.

Losartan is contraindicated also in pregnancy and lactation

• Action: It works by blocking the action of certain natural substances that tighten the blood
vessels, allowing the blood to flow more smoothly and the heart to pump more efficiently.

• Major side effects:

-Feeling dizzy
-Headache
-Nausea
-Vomiting
-Hypotension
-Hyperkalemia

• Nursing considerations:
-Regularly monitored for hypotension, renal function, and potassium levels.
-Notify physician immediately of pregnancy.
-Do not breastfeed while taking this drug.

Drug study #2
• Generic name: Omeprazole

• Brand name: Losec

• Classification: Proton Pump Inhibitor

• Indication:
 o Symptomatic GERD without esophageal lesions
o Erosive esophagitis
o Pathologic Hypersecretory conditions
o Duodenal cancer
o Helicobacter pylori infection
o Short-term treatment of active benign gastric ulcer
o Frequent heartburn
o Dyspepsia

• Doses/route/frequency: 40 mg TIV OD

• Contraindications:
• Contraindicated in patients hypersensitive to drug or its components and in patients receiving
rilpivirine-containing products.
Alert: High-dose, long-term PPI therapy may be associated with an increased risk of hip, wrist,
and spine fractures.
Bioavailability is increased in patients of Asian descent, and reduced doses are recommended
when used for healing EE.
• Use cautiously in patients with hypokalemia and respiratory alkalosis and in patients on a low-
sodium diet.
• Risk of fundic gland polyps increases with long-term use, especially beyond 1 year.
• Long-term administration of bicarbonate with calcium or milk can cause milk-alkali syndrome.
Dialyzable drug: Unlikely.
Overdose S&S: Confusion, drowsiness, blurred vision, tachycardia, nausea, vomiting,
diaphoresis, flushing, headache, dry mouth
• Action:
Inhibits proton pump activity by binding to hydrogen–potassium adenosine triphosphatase,
located at the secretory surface of gastric parietal cells, to suppress gastric acid secretion.
Route Onset Peak Duration PO 1 hr 30 min–2 hr.
Half-life: 30 to 60 minutes.
• Major side effects:
-CNS: asthenia, dizziness, headache. GI: abdominal pain, constipation, diarrhea, flatulence,
nausea, vomiting, acid regurgitation. Musculoskeletal: back pain, weakness. Respiratory: cough,
URI. Skin: rash.

• Nursing considerations:
-Alert: May increase risk of CDAD. Evaluate for CDAD in patients who develop diarrhea that
doesn't improve.
• False-positive results in diagnostic investigations for neuroendocrine tumors may occur due to
increased CgA level. Temporarily stop omeprazole treatment at least 14 days before assessing
CgA level and consider repeating the test if initial CgA level is high. If serial tests are performed
(e.g., for monitoring), the same commercial lab should be used for testing, as reference ranges
between tests may vary.
• Long-term therapy may cause vitamin B12 absorption problems. Assess patient for signs and
symptoms of cyanocobalamin deficiency (weakness, heart palpitations, dyspnea, paresthesia, pale
skin, smooth tongue, CNS changes, loss of appetite).
• Because risk of fundic gland polyps increases with long-term use, especially beyond 1 year, use
drugs for the shortest duration appropriate to the condition being treated.
 Dosage adjustments may be necessary in Asians and patients with hepatic impairment.
• Periodically assess patients for osteoporosis.
• Monitor patients for signs and symptoms of acute interstitial nephritis.
• Discontinue drug if signs or symptoms of cutaneous lupus erythematosus or SLE develop; refer
patient to the appropriate specialist for evaluation.
• Drug increases its own bioavailability with repeated doses. Drug is unstable in gastric acid; less
drug is lost to hydrolysis because the drug increases gastric pH.
• Gastrin level rises in most patients during the first 2 weeks of therapy.
Alert: Prolonged use of PPIs may cause low magnesium levels. Monitor magnesium levels before
starting treatment and periodically thereafter.
Alert: Monitor patients for signs and symptoms of low magnesium level, such as abnormal HR or
rhythm, palpitations, muscle spasms, tremors, or seizures. In children, an abnormal HR may
present as fatigue, upset stomach, dizziness, and light-headedness. Magnesium supplementation
or drug discontinuation may be required.
• Look alike–sound alike: Don't confuse Prilosec OTC with Plendil, Prevacid, prednisone, Pristiq,
Prozac, prilocaine, or Prinivil. Don't confuse omeprazole with aripiprazole, esomeprazole, or
fomepizole.

Drug study #3
• Generic name: Nicardipine Hydrochloride
• Brand name: Cardene, Cardene IV, Cardene SR
• Classification: Calcium channel blocker
• Indication: Chronic stable angina, given alone or with beta-adrenergic blockers. Hypertension
given alone or with other antihypertensives. Short-term treatment of hypertension when oral
therapy isn’t feasible or desirable.
• Doses/route/frequency:
20-40 mg P.O. (immediate release) t.i.d. wait at least 3 days before increasing release
0.5 mg/hour (equal to 20 mg P.O. q8 hours) for continuous IV infusion
• Contraindications:
-Hypersensitivity to drug
-Advanced aortic stenosis
• Action: Inhibits calcium transport into myocardial and vascular smooth muscle cells, causing
cardiac output and myocardial contractions to decrease.
• Major side effects:
CNS: dizziness, headache, asthenia, drowsiness, paresthesia
CV: hypotension, peripheral edema, chest pain, increased angina, palpitations
GI: nausea, dyspepsia, dry mouth
Musculoskeletal: myalgia
Skin: flushing
• Nursing considerations:
• Closely monitor BP and HR. Drug can cause symptomatic hypotension or tachycardia.
Measure Bp frequently during initial therapy. Maximal response occurs in about 1 hour.
Check for orthostatic hypotension. Because large swings in BP may occur based on drug
level, assess hypertensive effect 8 hours after dosing.
• Alert: Only immediate-release drug for is approved for treatment of angina.
To reduce the risk of venous thrombosis, phlebitis, and vascular impairment, don’t use
small veins such as those on the dorsum of the hand or wrist. Use extreme care to avoid
intra-arterial administration or extravasation.
• Look alike-sound alike: don’t confuse nicardipine with niacinamide, nifedipine, or
nimodipine. Don’t confuse Cardene with Cardura,Cardizem, or codeine.
Drug study #4
 • Generic name: Metoclopramide
• Brand name:
• Regal and Metozolv ODT
• Classification:
• Prokinetic agents
• Indication:
• To prevent or reduce nausea and vomiting
• To prevent or reduce postoperative nausea and vomiting
• To facilitate small-bowel intubation
• Delayed gastric emptying secondary to diabetic gastroparesis
• Gerd
• Dose/route/frequency:
• 10mg TIV q8h, PRN for nausea and vomiting
• Contraindication:
• Contraindicated in patients hypersensitive to drug and in those with pheochromocytoma.
• Contraindicated in patients for whom stimulation of GI motility might be dangerous.
• Action:
• Stimulates motility of upper GI tract, increases lower esophageal sphincter tone, and
blocks dopamine receptors at the chemoreceptor trigger zone.
• Major side effect:
• Drowsiness
• Excessive tiredness
• Weakness
• Headache
• Dizziness
• Diarrhea
• Nausea
• Vomiting
• Frequent urination
• Inability to control urination
• Nursing considerations:
• Monitor bowel sounds
• Safety and effectiveness of drug haven’t been established for therapy lasting longer than
12 weeks.
• Monitor patient for involuntary movements of face, tongue, and extremities.
• Monitor patient for fever, CNS symptoms, irregular pulse, cardiac arrhythmias, or
abnormal BP.
• Monitor patient for dizziness, headache, or nervousness after metoclopramide is stopped.

Drug study #5
• Generic name: Paracetamol

• Brand name: Tylenol

• Classification: Analgesic/antipyretic

• Indication: For mild to moderate pain and fever

 • Doses/route/frequency: 300 mg TIV q4h

• Contraindications: Severe hepatic impairment or active liver disease (IV)

• Action: Paracetamol has a central analgesic effect that is mediated through activation of
descending serotonergic pathways. Debate exists about its primary site of action, which may be
inhibition of prostaglandin (PG) synthesis or through an active metabolite influencing
cannabinoid receptors.

• Major side effects:

• an allergic reaction, which can cause a rash and swelling
• flushing, low blood pressure and a fast heartbeat – this can sometimes happen when
paracetamol is given in hospital into a vein in your arm
• blood disorders, such as thrombocytopenia (low number of platelet cells) and leukopenia
(low number of white blood cells)
• liver and kidney damage, if you take too much (overdose) – this can be fatal in severe
cases

• Nursing considerations:

-PRN for fever

Drug study #6
• Generic name: Diazepam
• Brand name: Diastat

• Classification: Anxiolytics, Benzodiazepines, Anticonvulsants, Benzodiazepine, Skeletal Muscle

Relaxants

• Indication: For seizure

• Doses/route/frequency: 1/2 amp IV PRN for seizure

• Contraindications:

-Documented hypersensitivity
-Acute alcohol intoxication
-Myasthenia gravis (allowable in limited circumstances)
-Acute narrow-angle glaucoma and open-angle glaucoma unless patients receiving appropriate
therapy
-Severe respiratory depression
 -Intravenous (IV) use in shock, coma, depressed respiration, patients who recently received other
respiratory depressants
-Sleep apnea
-Children under 6 months

• Action: Diazepam is a benzodiazepine tranquilliser with anticonvulsant, sedative, muscle relaxant

and amnesic properties. Benzodiazepines, such as diazepam, bind to receptors in various regions
of the brain and spinal cord. This binding increases the inhibitory effects of gamma-aminobutyric
acid (GABA). GABAs functions include CNS involvement in sleep induction. Also involved in
the control of hypnosis, memory, anxiety, epilepsy and neuronal excitability

• Major side effects:

- Low white blood cell count (neutropenia)

-Yellow skin or eyes (jaundice)
-Local effects: Pain, swelling, blood clot, carpal tunnel syndrome, dead skin
-Phlebitis if too rapid IV push

• Nursing considerations:

-Monitor V/S and NVS every hour and record

-Accurate I&O every shift and record

Drug study #7

• Generic name: Citicoline

• Brand name: Cognizin, Ceraxon

• Classification: Central stimulant, Nootropic agent

• Indication: Intramuscular, Intravenous-Cerebrovascular disorders, Cognitive disorder, Head

injury, Ischemic stroke, Parkinson's disease, Oral-Cerebrovascular disorders, Cognitive disorder,
Head injury, Ischemic stroke, Parkinson's disease

• Doses/route/frequency: 50 mg PO BID

• Contraindications: Hypertonia of the parasympathetic nervous system

• Action: Citicoline consumption promotes brain metabolism by restoring phospholipid content in

the brain and regulation of neuronal membrane excitability. It also influences the mitochondria or
energy factories of the brain cells and found to improve memory function. After several clinical
trials, Citicoline has been shown to raise the amount of acetylcholine in the brain.

• Major side effects: Bradycardia, tachycardia, Diplopia, epigastric distress, stomach pain, malaise,
Anorexia, Insomnia, Headache, Diarrhea

• Nursing considerations:
 -Monitor for adverse effect; instruct the patient to report immediately if she develops chest
tightness, tingling in mouth and throat, headache, diarrhea, and blurring vision.

-Monitor blood pressure, pulse rate and heart rate.

-Citicoline may be taken with or without food. Take it with or between meals.

-The supplement should not be taken in the late afternoon or at night because it can cause
difficulty sleeping.

Drug Study #8

• Generic name: Atorvastatin Calcium

• Brand name: Lipitor

• Classification: HMG-CoA reductase inhibitor

• Indication: Adjunct to diet for controlling LDL, total cholesterol, apo-lipoprotein B, and
triglyceride levels and to increase HDL levels in patients with primary hypercholesterolemia and
mixed dyslipidemia; primary dysbetalipoproteinemia in patients unresponsive to diet alone;
adjunct to diet to reduce elevated triglyceride levels.

• Doses/route/frequency: 40 mg PO OD

• Contraindications:

-Hypersensitivity to drug or its components

-Active hepatic disease or unexplained, persistent serum transaminase elevations

-Pregnancy or breastfeeding

• Action: Inhibits HMG- CoA reductase, which catalyzes first step in cholesterol synthesizes; this
action reduces concentrations of serum cholesterol and low-density lipoproteins (LDLs), linked to
increased risk of coronary artery disease (CAD). Also moderately increases concentration of
high-density lipoproteins (HDLs), associated with decreased risk of CAD.

• Major side effects: amnesia, anemia, rectal hemorrhage, thrombocytopenia, hepatic failure, toxic
epidermal necrolysis, bursitis, amblyopia

• Nursing considerations:

-Monitor liver function test results and blood lipid levels.

-Be aware that reduction in dosage and periodic monitoring of creatine kinase level may be
considered for patients taking drugs that may considered for patients taking drugs that may increase
atorvastatin level.

-Monitor patient for signs and symptoms of allergic response.

 -Caution the patient to avoid driving and other hazardous activities until he knows how drug effects
concentration, alertness, and vision.

-Tell the patient he may take drug with or without food.

Drug study #9

• Generic name: Linagliptin

• Brand name: Tradjenta

• Classification: dipeptidyl peptidase-4 (DPP-4) inhibitors.

• Indication: Indicated for the treatment of type II diabetes in addition to diet and exercise5. It
should not be used to treat type I diabetes or in diabetic ketoacidosis.

• Doses/route/frequency: 25 mg/tab, oral, OD

• Contraindications: Contraindicated in patients with a history of hypersensitivity to linagliptin,

such as anaphylaxis, urticaria, angioedema, exfoliative dermatitis or other serious allergic skin
condition (serious rash), or bronchial hypersensitivity.

• Action: It works by increasing the amounts of certain natural substances that lower blood sugar
when it is high.

• Major side effects:

-Bloating.
-Hives, welts, itching, or skin rash.
-Large, hard skin blisters.
-Large, hive-like swelling on the face, eyelids, lips, tongue, throat, hands, legs, feet, or sex
organs.
-Pains in the stomach, side, or abdomen, possibly radiating to the back.
-Severe joint pain.

• Nursing considerations:
-Assess the patient’s medical history and current medications.
-Monitor blood glucose levels.
-Educate the patient on proper medication use.
-Blood and urine tests may be needed to check for unwanted effects.
-Check with your doctor right away if you have a sudden and severe stomach pain, chills,
constipation, nausea, vomiting, loss of appetite, fever, or lightheadedness.
Drug study #10

• Generic name: Lactulose syrup

• Brand name: Constulose, Enulose, Generlac, Kristalose

• Classification: Ammonium Detoxicants, Laxatives, Osmotic

• Indication: Lactulose is used to treat constipation and portal systemic encephalopathy.

• Doses/route/frequency: 30 cc ODHS PO

• Contraindications: Galactosemia (patients require low-galactose diet)

• Action: Chief mechanism of action is by decreasing the intestinal production and absorption of
ammonia. It has also gained popularity as a potential therapeutic agent for the management of
subacute clinical encephalopathy. It is also a laxative for the treatment of chronic constipation.

• Major side effects:

- dehydration
-diarrhea
-excessive bowel activity
-high blood sodium levels
-low blood sodium levels
-nausea
-vomiting
-abdominal cramping
-abdominal distention
-burping (belching)
-gas (flatulence)

• Nursing considerations:
-Monitor blood sugar for diabetes (preparation contains lactose and galactose)
-Monitor for electrolyte imbalance when the drug is used for longer than 6 months or in patients
predisposed to electrolyte abnormalities
-Avoid using other laxatives concomitantly
-Inadequate response possible when taken concomitantly with anti-infective
-Lactulose use during pregnancy may be acceptable. Either animal studies show no risk, or
human studies are not available or animal studies showed minor risks, and human studies were
done and showed no risk
-It is unknown if lactulose is distributed into breast milk; use with caution
VII. Conclusion
The second most common cause of mortality worldwide is stroke. Each year, it affects 13.7
million people and kills about 5.5 million. The prevalence of ischemic infarctions, which account for
about 87% of strokes, grew significantly between 1990 and 2016, which is attributed to lower mortality
and better clinical interventions. The majority of strokes are caused by primary (first-time) hemorrhages,
with secondary (second-time) hemorrhages accounting for between 10% and 25%. Over the period 1990–
2016, the incidence of stroke increased in low- and middle-income countries, while it decreased by 42%
in high-income nations. Stroke is a very serious matter, it can be fatal if there is no immediate action. So
it is very important that every individual in our society know how to assess for a stroke.

REFERENCES:
McGraw-Hill Nurse’s Drug Handbook Seventh Edition
Natale, N., Petit, R., Champane, J., Rodriguez, C., Ladna, J., & Savu, C. (2021). A Rare Presentation of
Posterior Cerebral Artery Stroke With Monocular Hemianopia After Diesel Exposure. Cureus, 13(5),
e14977. https://doi.org/10.7759/cureus.14977
https://www.physio-pedia.com/home/
Charlick M, M Das J. Anatomy, Head and Neck: Internal Carotid Arteries. [Updated 2022 Jul 25]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK556061/
Adigun OO, Reddy V, Sevensma KE. Anatomy, Head and Neck: Basilar Artery. [Updated 2022 Aug 8].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459137/
Ali F, Reddy V, Dublin AB. Anatomy, Back, Anterior Spinal Artery. [Updated 2022 Jul 25]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK532963/
Saini, V., Guada, L., & Yavagal, D. R. (2021). Global Epidemiology of Stroke and Access to Acute
Ischemic Stroke Interventions. Neurology, 97(20 Suppl 2), S6–S16.
https://doi.org/10.1212/WNL.0000000000012781