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Clinical Assessment Of TIA Leading To Stroke

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Question:

You are required to demonstrate your understanding through guided application of the subjective and objective data gained from a patient situation to selected components of the clinical reasoning cycle.
 
 

Answer:

Patient situation:

A 59 year old widow named Mrs. Amari was brought to the emergency department by her son, Niko. He noticed a sudden slurring in her mother’s speech with drooped face on one side. She reported her son about the numbness of right side of her face including her right arm. Niko brought her to the hospital after having a fear of stroke.

Previous history:

Her mother had a history of hypertension with hypercholesterolemia with 25 years of tobacco usage which she had stopped ten years ago. She showed a positive history of family line with heart disease. She does not follow a regular exercise regimen with occasional walk in neighbourhood.

Primary assessment:

The nursing staff in the emergency department assessed her and found a slight diversion of mouth in the right side with speech slightly slurred. Further assessment showed no such weakness with steady gait and could swallow without any difficulty.  She followed all the commands and looked oriented. The pupal examination showed round, equal and normally reacting to light (4mm to 2mm). No such nystagmus was noted. She did not complain of any kind of headache followed by nausea, vomiting, chest pain, diaphoresis or visual complaints.

 

Information gathered:

On examining her vital signs her temperature was 36.7ºC with an increased blood pressure of 148/97mmHg, pulse recorded 81, respiratory rate was 14 and the oxygen saturation was 94%. Numbering through Glasgow Coma Scale showed 15 with 6.6mmol/L blood glucose level. Based on the history and examination result she was diagnosed by a transient ischemic attack (TIA) also termed as mini attack. A scan of the head computed tomography (CT) showed no such change in intracranial structure with MRI (Magnetic Resonance Imagery) reports normal. The neurologist referred her to the stroke unit for further observation followed by treatment.

Current situation:

The visit to Mrs. Amari in the next day showed some changes in the clinical features. Her speech sounded slurry with drooped mouth in the right side. Examining her vital signs should an elevated change in blood pressure to 175/105mmHg with decrease in the SpO2 by 92%. The examination history showed consistency with the TIA. The change in the vital signs with increased ABCD scores (The Airway, Breathing, Circulation, Disability) constituted a risk of stroke in the upcoming 48 hours (Daniels et al. 2012). Hence, in this clinical report based on the case study of Mrs. Amari the methods relating the assessment, diagnosis and management of TIA followed by stoke signs will be evaluated with required interventions.

Epidemiology with aetiology:

Transient ischemic attack (TIA) is a common clinical disorder with incidental rate of 0.5 out of 1000 people. It usually affects the communication, motor functioning and sensibility. TIA is often followed by strokes which go unrecognised in patients (Hickey 2012). This symptom occurs when the blood vessel inside the brain is clogged (Figure 1). This clinical presentation occurs due to death of the brain cells (Rosenberg 2012). TIA differs from stroke in duration of the symptom, in which TIA does not persist more than one hour. Obstructed blood flow termed ischemia causes permanent damage in brain causing (CVA) cerebrovascular accident (Sanderson et al. 2013). In TIA brain shows temporary damage. CVA with ruptured artery with bleeding within brain is called haemorrhage. TIA and stroke are distinguished depending on the cause. Hence, the patients with TIA can be cured by early recognition and by preventing other disabling events. Therefore, a thorough knowledge about the various mechanisms is important to provide exact treatment and thereby preventing death.

Undertaking the diagnosis:

TIA onsets suddenly and hence need immediate assessment. It is a neurological deficit of transient focal whose symptoms appears in late stage, thus proper diagnosis is required from examining and investigating (Riccio et al. 2013). Headache is sometimes perceived to be a part of TIA syndrome but severe headache is rarely noticed in TIA.

 

TIA symptoms:

The symptoms of TIA are feeling of numbness with unilateral weakness, slurred speech and defect in vision which was noted in Mrs. Amari. In this case the anterior circulation that involves the circulation of carotid artery is affected. Other symptoms are found in posterior circulation with affected system of vertebro-basilar. Thus, by understanding the symptoms pattern, exact diagnosis can be made.

Investigations:

The patient’s diagnosed with TIA should be assessed by primary investigation such as blood glucose test, routine check up of blood pressure and pulse with frequent ECG. The assessment should involve ABCD2 score for analysing the stroke risk with a score of four or above and should be recommended for carotid imaging to detect the stenosis of carotid artery (Sanders et al. 2013).  In many hospitals, TIA assessment is done regularly in patient with urgent need.

Stroke risk ABCD2 score:

1. Age >60 years - 1 point

2. BP >140/90mmHg - 1 point

3. Clinical components: Unilateral weakness- 2points

                                       Speech affected without weakness- 1 points

4. Symptoms duration: more than 60 minutes- 2 points

                                      10 to 59 minutes- 1 point

5. Diabetes - 1 point

Apart from scoring the symptoms, further investigations will be carried out by brain imaging. Magnetic Resonance Imaging (MRI) of diffused weighted is done within a week in patients with low risk and within one day for patients with high risk. Advanced investigation can be done by CT (computed tomography) that identifies the haemorrhages and the lesions occupying the spaces. The patients with TIA diagnosed be provided Doppler ultrasonography in order to examine the disease associated with carotid along with vertebra-basilar.  Other tests such as Halter monitoring with ECG (electrocardiogram) can be necessitated (Somford et al. 2013).

Management of the situation:

The TIA management with diagnosis is same in both cases of TIA and stroke. Although, stratified risks in TIA allows the treatment specialist to decide where and when to make the referral. Therefore, it is important to evaluate the management of the aggressive risk components. The advice regarding the lifestyle should point out as much as possible risk factors. The specific interventions in reducing the rate of stroke have been discussed below (Ihle?Hansen et al. 2014)

 


Hypertension treatment: Treating hypertension by reducing the BP with antihypertensive can prevent the recurrent stroke along with other vascular problems after TIA. Combined use of diuretics with ACE inhibitors are found to reduce the BP by approximately 10/5mmHg (Bunker 2014). Hypertension was recorded in the history of Mrs. Amari which can be controlled by this treatment.

Hypercholesterolaemia:  The drugs related to lowering of cholesterol have been found to be effective in primary as well as secondary prevention (Rabar et al. 2014). Diets should be modified with statin use if the total count is more than 3.5mmol/L. Mrs. Amari showed hypercholesterolemia which can be controlled by this intervention.

Smoking: Smoking is one of the leading causes for 50% stroke rise. Thus, patients with TIA and strokes should be recommended to quit smoking (Peters, Huxley & Woodward 2013). Mrs. Amati had a smoking history of 25 years but had quit few years back.

Anticoagulants: About 15% of TIA and ischemic strokes are intervened by anticoagulants based warfarin (Easton et al. 2012). Dabigatran is a new anticoagulant which has newly emerged but due its cost and irreversible nature, it is detrimental to life.

Diabetes: The diabetic patients with TIA or stroke need strict control of glucose level in order to reduce the vascular related complications (Schnell, Erbach & Hummel 2012).

Antiplatelets such as aspirin are used in patients with past record of TIA or any kind of stroke to reduce the vascular risks by 13% (Geeganage et al. 2012). But aspirin should not be administered without doing brain imaging.

 

Prognosis:

The prognosis is linked with timely diagnosis of TIA followed by stroke referring to an immediate treatment with secondary prevention. The TIA prognosis is concerned with stroke risk followed by vascular events. Statistical studies have shown that 70% patients couldn’t recognise TIA which delayed in getting medical help (Spurgeon et al. 2012). Therefore, the people should be educated for estimating the risk with proper planning programme and regular check up by specialist.

Preventing future occurrence:

Recurrent occurrence can be controlled by adjusting the diet with modified lifestyle such as smoking, physiological stress with hypertension and elevated cholesterol level with medical interventions. Modification in these risk factors can lower the risk of future stroke recurrence in patients diagnosed with TIA

 

References:

Bunker, J 2014, ‘Hypertension: diagnosis, assessment and management’, Nursing Standard, vol. 28, no. 42, pp.50-59.

Daniels, EC, Powe, BD, Metoyer, MT, McCray, MG, Baltrus, P & Rust, GS 2012, ‘Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers: the ABCD community intervention pilot project’, Journal of the National Medical Association, vol. 104, p.179.

Easton, JD, Lopes, RD, Bahit, MC, Wojdyla, DM, Granger, CB, Wallentin, L, Alings, M, Goto, S, Lewis, BS, Rosenqvist, M & Hanna, M 2012, ‘Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial’, The Lancet Neurology, vol. 11, no. 6, pp.503-511.

Geeganage, CM, Diener, HC, Algra, A, Chen, C, Topol, EJ, Dengler, R, Markus, HS, Bath, MW, Bath, PM & Acute Antiplatelet Stroke Trialists Collaboration 2012, ‘Dual or mono antiplatelet therapy for patients with acute ischemic stroke or transient ischemic attack’, Stroke, vol. 43, no. 4, pp.1058-1066.

Hickey, K 2012, ‘Anticoagulation management in clinical practice: preventing stroke in patients with atrial fibrillation’, Heart & Lung: The Journal of Acute and Critical Care, vol. 41, no. 2, pp.146-156.

Ihle?Hansen, H, Thommessen, B, Fagerland, MW, Øksengård, AR, Wyller, TB, Engedal, K & Fure, B 2014, ‘Multifactorial vascular risk factor intervention to prevent cognitive impairment after stroke and TIA: a 12?month randomized controlled trial’, International Journal of Stroke, vol. 9, no. 7, pp.932-938.

Peters, SA, Huxley, RR & Woodward, M 2013, ‘Smoking as a risk factor for stroke in women compared with men,’ Stroke, vol. 44, no. 10, pp.2821-2828.

Rabar, S, Harker, M, O'flynn, N & Wierzbicki, AS 2014, ‘Lipid modification and cardiovascular risk assessment for the primary and secondary prevention of cardiovascular disease: summary of updated NICE guidance’, BMJ: British Medical Journal (Online), 349.

Riccio, PM, Klein, FR, Cassará, FP, Giacomelli, FM, Toledo, MEG, Racosta, JM, Delfitto, M, Roberts, ES, Bahit, MC & Sposato, LA, 2013, ‘Newly diagnosed atrial fibrillation linked to wake-up stroke and TIA Hypothetical implications’, Neurology, vol. 80, no. 20, pp.1834-1840.

Rosenberg, GA 2012, ‘Neurological diseases in relation to the blood–brain barrier’, Journal of Cerebral Blood Flow & Metabolism’, vol. 32, no. 7, pp.1139-1151.

Sanders, LM, Srikanth, VK, Blacker, DJ, Jolley, DJ, Cooper, KA & Phan, TG ‘2012. Performance of the ABCD2 score for stroke risk post TIA Meta-analysis and probability modeling’,  Neurology, vol. 79, no. 10, pp.971-980.

Sanderson, TH, Reynolds, CA, Kumar, R, Przyklenk, K & Hüttemann, M 2013, ‘Molecular mechanisms of ischemia–reperfusion injury in brain: pivotal role of the mitochondrial membrane potential in reactive oxygen species generation’, Molecular neurobiology, vol. 47, no. 1, pp.9-23.

Schnell, O, Erbach, M & Hummel, M, 2012, ‘Primary and secondary prevention of cardiovascular disease in diabetes with aspirin’, Diabetes and Vascular Disease Research, vol. 9, no. 4, pp.245-255.

Somford, DM, Hoeks, CM, Hulsbergen-van de Kaa, CA, Hambrock, T, Fütterer, JJ, Witjes, JA, Bangma, CH, Vergunst, H, Smits, GA, Oddens, JR & van Oort, IM 2013, ‘Evaluation of diffusion-weighted MR imaging at inclusion in an active surveillance protocol for low-risk prostate cancer’, Investigative radiology, vol. 48, no. 3, pp.152-157.

Spurgeon, L, Humphreys, G, James, G & Sackley, C, 2012, ‘A Q-methodology study of patients’ subjective experiences of TIA’, Stroke research and treatment, 2012.

Tarola, G & Phillips, RB 2015, ‘Chiropractic response to a spontaneous vertebral artery dissection’, Journal of chiropractic medicine, vol. 14, no. 3, pp.183-190.

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