A journey from thrombolysis for ischemic stroke to decompressive craniectomy and lifesaving fasciotomy

Jenma Rakkini1*, Maha Lakshmi2

1Nurse Supervisor Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

2Nursing Superintendent, Kauvery hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence

Abstract

A 35-year-old male with no previous health problems presented with giddiness followed by a fall from a bike. He developed weaknesses on the right side of the body and slurred speech. He was taken to the emergency department, where early assessment and MRI confirmed a diagnosis of stroke. The patient was treated within the golden hour with thrombolytic therapy (Tenecteplase). Early recognition and timely management helped improve the patient’s outcome.

Key words: Thrombolytic therapy (Tenecteplase); Stroke; Slurred speech

Introduction

Stroke is a medical emergency that occurs due to interruption of blood supply to the brain. Early identification of symptoms such as weakness, speech difficulty, and facial deviation is very important for effective treatment. Timely intervention, especially within the golden hour, can significantly reduce complications and improve recovery. This case highlights the importance of early diagnosis and prompt management in stroke care.

Case Presentation

A case of a 35-year-old male with nil co-morbidities presented with the history of giddiness and followed by skid and fall from bike on 17/06/25 around 09:30 am. The patient has developed right upper and lower limb weakness, slurring of speech, aggregation of angle of mouth deviation to left side. In the Emergency department, patient GCS was E4V5M6 and underwent the investigation of the MRI stroke protocol. Within the Golden hours, patients affected with stroke were diagnosed with the underlying MRI scan and clinical manifestations. So, Inj.Tenecteplased was injected and thrombolysis was initiated.

Relevant Clinical Findings

Social History: He has a history of cigarette smoking for five years but not an alcoholic.

Allergic History: No medicine known or environmental allergies.

Family History: There is no family history of neurological disorders.

Physical Examinations

In emergency department

Vital signs

Temp98.1F
Pulse116 beats/min
RR22 breaths/min
Blood pressure110/60 mm Hg
Saturation of oxygen 97%

ABCDE Assessment

A = Patient vocalizing no obstructions in airways

B = Spontaneous. Bilateral depth adequate. RR 22 breaths/min

C = All peripheral nerve pulses present. HR: 88 beats /min, BP: 130/90 mm Hg. pallor and oedema

D = Neurological Examination

Gait: Shuffling gait with reduced arm sling, Difficult in turning, occasional freeing episodes

E = No pressure injury and no other external injury noted.

Relevant Investigation

ParameterValue
Test (PT)12.9 Sec
Control (PT)11.4 Sec
INR1.3
Test (APTT)31.5 Sec
Control (APTT)26.1 Sec
Haemoglobin9.2 g/dl
Packed Cell Volume29.3 %
Total Count1713 Cells/mm3
Platelets605000 Cells/mm3
Urea34.24 mg/dL
Creatinine0.84 mg/dL
Sodium130 mmol/L
Potassium4.84 mmol/L

MRI of brain screening – Report 17.06.2025

The acute infarct left MCA territory with minimal mass effect

Multislice CT scan brain plain study – 17.06.2025

Acute infarct in left temporo – parietal cortex with minimal mass effect

Multislice CT scan brain plain study – 18.06.2025

Acute infarct in left MCA and ACA territory with mass effect and midline shift

Right lower limb – Arterial study 19.06.2025

Echogenic thrombus in right CFA causing partial luminal occlusion

Carotid and vertebral doppler study – Bed side 19.06.2025

Normal doppler study of bilateral carotid arteries, Normal bilateral vertebral arteries

Multislice CT lower peripheral angiogram – Report 19.06.2025

Thrombosis in the distal external iliac artery on right side with partial luminal narrowing with normal opacification of common femoral artery, superficial femoral artery up to the middle 1/3RD with thrombus causing complete occlusion with non – visualization of the arteries distal to it. The left lower limb artery shows normal opacification.

Multislice CT scan brain plain study – 23.06.2025

Postoperative bony defect left fronto – temporo – parietal region with infarct in left MCA and ACA territory with minimal mass effect

Multislice CT scan brain plain study – 24.06.2025

K/c/o Left ACA and MCA territory infarct status post craniectomy, on follow-up

Subacute infarct with hemorrhagic transformation seen in left frontal parietal and temporal lobes

Right lower limb – Arterial doppler study – Bedside (24.06.2025)

  • Biphasic flow from right common femoral to distal posterior tibial arteries
  • Monophasic spectrum in distal anterior tibial and dorsalis pedis arteries

Diagnosis

  • Young stroke
  • Malignant left ICA infarct – right hemiparesis
  • Thrombolysis is done with Tenecteplase
  • Right femoral artery thrombosis
  • Lupus anticoagulant positive
  • Hyperhomocysteinemia
  • Right leg compartment syndrome
  • Sepsis
  • Tracheal culture – pseudomonas aeruginosa
  • Tissue / blood culture – Acinetobacter spp (MDR strain)
  • Tissue / pus – klebsiella pneumoniae / pseudomonas aeruginosa

Management

Thrombolytic Therapy: The patient was thrombolysed with the injection Tenecteplase 16mg within golden hours

Antiplatelet & antihyperlipidemic Agent: Patient was started on tablet Atorvastatin 80mg HS and Tablet Aspirin 75mg OD via nasogastric tube

Anticoagulant Therapy: Injection Heparin infusion and split doses as administered as per doctor’s advice

Supportive Management

Blood Pressure Control

  • Maintain blood pressure < 180/110 mmHg if considering thrombolysis
  • Continuous monitor of Blood pressure

Volume Expansion

  • Administration of high dose albumin and hemodilution by volume expansion

Temperature

  • Anti-pyretic agents like paracetamol and cooling devices might be used
  • Relevant antibiotics were used

Surgical Management

  • Emergency Left Fronto-Parietal decompressive Craniotomy/temporal lobectomy and cisternostomy were performed because of CT brain done and revealed that new onset of ACA tertiary- Acute with midline shift and mass effect on 18/06/2025
  • Right leg thrombectomy and compartmental fasciotomy was done on 19/06/2025
  • On 23/06/2025 patients underwent the procedure of Re-debridement of right leg Fasciotomy was performed
  • Followed by 30/06/2025 tracheostomy was done under aseptic procedure.

Outcome

Post procedurally, he developed septic shock requiring prolonged ventilation, intravenous fluid support, inotropes and supportive management. Empirical antibiotics were started. The patient was stabilized in important condition with follow-up plans.

Nursing Management

  • Monitored vital signs and GCS
  • Continuous IV fluids, anticoagulants, anti-lipidemic and antiplatelet drugs
  • The patient initially was on nasogastric feeding and then an oral trial was done. High rich protein and fiber diet were prescribed
  • Intravenous opioids like infusion of fentanyl and midazolam were administered
  • Relaxation techniques, music therapy and positioning for comfort may also aid in pain relief and emotional support given to the patient
  • Maintained strict hand hygiene and moments
  • Used clean and appropriate dressing as per wound type
  • Performed regular dressing
  • Ensured airway patency by frequent suctioning using sterile techniques
  • Ensured tracheostomy ties and secure but not too tight
  • Coordination with vascular and ENT for follow up care
  • Maintained Intake and Output chart and electrolytes imbalance
  • Prevention of pressure sores through positioning, respiratory precautions maintained and stress management
  • Prevent CLABSI, VAP, CAUTI, SSI etc.

Discharge Medications

DrugDose
Tab Eliquis2.5 mg
Tab Brivaracetam50 mg
Tab Atorvastatin80 mg
Tab Paracetamol 1 gm
Tab Clonazepam1 mg
Tab Ecospirin75 mg
Tab Ranitidine150 mg
  • Diet education about low salt, sugar and fat explained the patient attender
  • Explained about the importance of physiotherapy and rehabilitation Centre
  • Avoid alcohol and Smoking
  • Regularly check the blood pressure, sugar and cholesterol level
  • Take medication on time

Conclusion

Stroke is a potentially life-threatening condition that may compromise patient airway safety and health. A multi-disciplinary approach is essential to manage the acute phase, prevent complications and ensure a smooth transition to recovery or long-term care. Ultimately timely interventions and comprehensive nursing management can significantly improve prognosis and quality of life for patients.

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