A Case of Stroke

Mariya Rosy1, Kalaiselvi2, Subadhra Devi. M3, Maha Lakshmi4

1ER Nurse, Kauvery Hospital, Cantonment

2Nursing Supervisor, Kauvery Hospital, Cantonment

3Nurse Educator Kauvery Hospital, Cantonment

4Nursing Superintendent, Kauvery hospital, Cantonment

Abstract

Stroke is a leading cause of morbidity and mortality worldwide, characterized by sudden disruption of cerebral blood flow due to ischemia or hemorrhage. Ischemic strokes account for approximately 87% of cases, often resulting from thrombotic or embolic occlusion of cerebral arteries. Hemorrhagic strokes occur due to rupture of aneurysms or small vessels. Prompt recognition and treatment are crucial to minimize brain damage and improve outcomes. Symptoms may include sudden weakness, numbness, facial drooping, slurred speech, and vision changes. Timely interventions, such as thrombolytic therapy and endovascular procedures, can significantly impact patient recovery. Comprehensive stroke care involves multidisciplinary teams, including neurologists, radiologists, and rehabilitation specialists, working together to provide optimal acute and long-term management.

Introduction

Stroke is a complex and multifaceted medical condition characterized by the sudden interruption of blood flow to the brain, resulting in tissue damage and loss of brain function. It is a leading cause of morbidity and mortality worldwide, with significant implications for individuals, families, and healthcare systems. The two primary types of stroke are ischemic and hemorrhagic, each with distinct pathophysiological mechanisms and treatment approaches. Ischemic strokes, accounting for approximately 80-90% of cases, occur when a blood vessel supplying oxygen and nutrients to the brain is occluded, often due to thrombosis or embolism. Hemorrhagic strokes, on the other hand, result from the rupture of blood vessels, leading to bleeding into or around the brain. Understanding the causes, risk factors, and clinical manifestations of stroke is essential for providing timely and effective care.

Case presentation

A 73-year-old female patient with a known history of acute-on-chronic kidney disease (CKD), systemic hypertension, and cardiac illness presented with sudden onset of unsteadiness, right upper and lower limb weakness, and decreased sensation. The patient had been on Dabigatran, a direct oral anticoagulant, but had discontinued treatment for a month prior to the presentation. Around 7.00 am of February 20, 2025, she experienced symptoms that prompted her to seek medical attention at an outside hospital by 7:30 a.m. There, a cardiologist evaluated her and noted bradycardia. An echocardiogram revealed normal left ventricular function with no regional wall motion abnormalities (RWMA). Given her complex presentation, the patient was referred to our facility for further management.

Upon evaluation, the patient’s symptoms suggest a possible stroke or transient ischemic attack (TIA), warranting urgent neurological assessment and imaging studies, such as CT or MRI scans, to determine the cause and extent of brain involvement. Considering her history of CKD and recent discontinuation of anticoagulation therapy, careful consideration of her renal function and coagulation status will be essential in guiding management decisions.

Social History

She does not have any history of cigarette smoking, alcohol addiction.

Allergies

No known medicine or environmental allergies

Past Medical History:

Coronary Artery disease/paroxysmal AF, Acute CKD, systemic hypertension. She was on regular treatment

Family History:

No family history of similar neurological disorders.

Physical Examination:

Vital signs Temp: 98.2-degree farenhit.HR:58/min, RR:20/min BP 110/60 mmHg Spo2 :98%

A: Patient vocalizing no obstruction in airways

B: Spontaneous. Bilateral depth adequate, RR:16/min

C: All peripheral pulse present.HR 74/min BP 130/80 mm Hg, No pallor, icterus, or pedal edema

D: Neurological Examination:

  • Cognition: Intact, MMSE score: 28/30
  • Cranial Nerves: Normal
  • Motor System:

Resting tremor (4-6 Hz) in the right upper limb

Bradykinesia with slow finger tapping and hand movements

Cogwheel rigidity in both upper limbs

  • Gait:

Shuffling gait with reduced arm swing

Difficulty in turning, occasional freezing episodes

  • Postural Instability: Positive pull test (falls after a slight backward pull)

E: No pressure injury and no other external injury noted

Investigations:

POCUS:

Bilateral renal parenchymal changes

GB wall edema

Echo showed

AF During study

RA mildly Dilated

No RWMA

Good LV Function

Grade -2-LV Systolic & Diastolic dysfunction

Mild MR/Mild AR

Markable investigations

Calcium Free Ionized1.18 mg/dL
Calcium Serum9.2 mg/dL
Chloride114 mmol/L
Creatinine2.0 mg/dL
Phosphorous2.4 mg/dL
Potassium4.9 mmol/L
Sodium.142 mmol/L
Thyroid Stimulating Hormone (TSH)2.30 µIU/L
Total Cholesterol130 mg/dL
Total Protein6.68 g/dl
Urea Serum68.48 mg/dL
Vitamin D Total 25 Hydroxy34.1 ng/mL
(MCHC) Mean Corpuscular Haemoglobin Concentration31.4 g/dl
Basophil0.20%
Haemoglobin12.9 g/dl
Haemoglobin12.6 g/dl
Lymphocyte14.90%
Monocyte4.50%
Neutrophil78.90%
Packed Cell Volume (PCV)38.80%
Platelet Count140000 cells/µl
Polymorphs70.90%
Test (APTT)32.3 Seconds
Test (PT)12.4 Seconds
Total RBC Count4.26 10^9/cumm
Total WBC Count6650 Cells/Cumm
INR1.10
RDW - CV14.20%
C Reactive Protein (CRP)168.06 mg/L
CA++(7.4)1.21 mmol/L
Lac1.1 mmol/L
Direct Bilirubin0.55 mg/dL
Total Bilirubin1.32 mg/dL

Imaging examination

CT brain – 20.2.25

Acute non-hemorrhagic infract in left MCA territory

Age related Atrophy

CT brain – 21/2/25

Sub-Acute infract in left MCA territory infract with grade 2 hemorrhagic transformation mass effect with no significant midline shift

Age related Atrophy

Carotid & Vertebral Doppler done: Mild atherosclerotic changes in bilateral carotid system

Normal bilateral Vertebral arteries

Echocardiogram

AF During study

RA mildly Dilated

No RWMA

Good LV Function

Grade -2-LV Systolic & Diastolic dysfunction

Mild MR/Mild AR

The patient had also been on Dabigatran but had discontinued the anticoagulant approximately one month prior to presentation. On the morning of 20/02/2025 at 7:00 a.m., she experienced a sudden onset of unsteadiness, accompanied by weakness in the right upper and lower limbs, as well as diminished sensation on the same side.

She was taken to a nearby hospital around 7:30 a.m., where initial evaluation by a cardiologist revealed bradycardia. An echocardiogram performed at that facility showed normal left ventricular (LV) function with no regional wall motion abnormalities (RWMA). In view of the neurological symptoms and stable cardiac findings, the patient was referred to our tertiary care center for further evaluation and management.

Upon arrival, a stroke protocol was initiated. Given the focal neurological symptoms with unilateral weakness and sensory loss, a cerebrovascular event—most likely an ischemic stroke—was strongly suspected. Additional work-up including neuroimaging (CT/MRI brain), coagulation profile, renal function tests, and assessment of anticoagulation status was planned. The discontinuation of Dabigatran, combined with her history of cardiac illness and CKD, placed the patient at increased risk of thromboembolic events.

The early identification of symptoms and prompt referral for specialized care are critical in optimizing outcomes in stroke management. This case highlights the importance of medication adherence, especially in patients with atrial fibrillation or other cardiac conditions requiring anticoagulation, to prevent cerebrovascular accidents.

Management:

Thrombolytic Therapy:

The patient was thrombolyted with Inj. Tenecteplace as per within the window period. Had bradycardia, Dopimine infusion was initiated. She was shifted to Stroke ICU.

Antiplatelet Therapy:

Start ECOSPIRIN  75mg orally or via nasogastric tube after ruling out hemorrhagic stroke.

Consider Aztorl in dual therapy if indicated.

Supportive Management

Blood Pressure Control:

Maintain BP <185/110 mmHg if, considering thrombolysis.

If not a thrombolysis candidate, tolerate BP up to 220/120 mmHg unless end-organ damage exists.

Hydration and Renal Function:

Carefully managed IV fluids due to underlying CKD.

Monitored serum creatinine, electrolytes, and urine output closely.

Follow up treatment.

Inj. Magnex 1 GM
Tab. Storcit Plus
Tab. Ecospirin 75 MG
Tab. Aztor 40 MG
Tab. Pan 40 MG
Tab. Reniguard
Tab. Nodosis 500 MG

Skilled Nursing Care in Idiopathic Parkinson’s Disease

Stroke is a severe and potentially life-threatening condition, that requires prompt & comprehensive treatment skilled nursing care plays a vital role managing this condition reducing complication and patient outcomes

Close monitoring:

Maintain BP <185/110 mmHg if considering thrombolysis.

Closely monitored patient vital signs, laboratory values and clinical to quickly identify any changes or complications

Neurological status:

Skilled nurses should monitor the patient closely for neurological deficit and inform the clinician. The bed railing should be raised because there is high risk of fall. Also monitor,

Mental status

Motor Examination

Sensory Examination

Co ordination

Reflexes & Gait station

Nutritional support:

It is a Crucial role is ensuring adequate nutritional support for stroke patient, particularly those at risk of malnutrition, this includes assessing nutritional status, identifying swallowing difficulties(dysphagia) and initiating and monitoring.

Enteral feeding can be considered.

Complications

Atelectasis

De conditioning

Pressure ulcer

Fall

Health Education:

Regular exercise

Don’t smoke and minimize alcohol consumption; also consider physical therapy, occupational therapy, and speech therapy.s

Conclusion:

Her acute onset of right-sided weakness and sensory loss, coupled with unsteadiness, is strongly suggestive of a cerebrovascular event, most likely an ischemic stroke. Although initial evaluation at an outside hospital revealed bradycardia and a structurally normal heart on echocardiogram (with no regional wall motion abnormalities), the clinical picture warranted urgent neurological assessment and imaging.

This case underscores the importance of timely recognition and referral in acute stroke presentation, as well as the critical role of anticoagulation in high-risk patients with cardiac comorbidities. The interruption of anticoagulant therapy without appropriate medical guidance likely contributed to the development of the current event. Comprehensive stroke care, including imaging, neurological evaluation, and rehabilitation, is essential to prevent long-term disability.

Moreover, this highlights the need for patient education on medication adherence, regular follow-up, and integrated care approaches in managing elderly patients with multiple chronic conditions.

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