Pathophysiology of Hemorrhagic and Ischemic CVA - Coursework Example

Stroke Student’s name Institution Introduction The symptoms of hemorrhagic CVA and ischemic CVA are similar therefore making it critical for the medical practitioner to differentiate the two in making of diagnosis or in prescription of medications. Pathophysiology of Hemorrhagic and Ischemic CVA Ischemic stroke refers to a stroke which occurs when there is a blockage or narrowing of the arteries in the brain which results in significant reduction in blood flow. The most common of ischemic stroke are the thrombotic stroke and the embolic stroke. The thrombotic stroke is caused by a blood clot in the arteries supplying the brain. An embolic stroke is as a result of a blood clot or other blockage happening in another area of the body usually the heart which goes on to be transported to the narrower brain arteries causing blockage (Kiely & Nicholas, 2010). Ischemic CVA is precipitated by a range of factors such as hypertension, diabetes, age, and family history of stroke, personal history of stroke, atrial fibrillation and lack of physical activity (Ansell, 2010). Mrs. Middleton is 68 thus older than the above 55 age, she has a blood pressure above normal, she also has a history of hemorrhoids which may cause an ischemic blockage. Hemorrhagic CVA refers to a stroke resulting from the rupturing or leaking of a blood vessel in the brain. It may result from hypertension and weakness in the blood vessels referred to as aneurysms. It may also result from the abnormal tangle of thin walled blood vessels rupturing. Intracerebral hemorrhage and subarachnoid hemorrhage are the most common types of hemorrhagic CVA. Intracerebral hemorrhage is the rupturing of blood vessels in the brain which results in blood spilling into brain tissue which damages brain cells (Kasner & Gorelick, 2013). Subarachnoid hemorrhage occurs when a blood vessel ruptures and spills blood in the inter-cranial surface. In most instances it is caused by the rupture of an aneurysm which may cause migraines and vasospasms which would damage brain cells further by limiting blood flow (Nentwich, Magauran & kahn, 2012). Ischemic risk increases with systolic blood pressure level which is also influenced by such modifiable factors such as thrombolytic therapy, familial history of stroke, anticoagulation, heavy alcohol use, blood thinning medications and cocaine. Hypertension is an independent precipitating factor of hemorrhagic CVA but it is not as strong as smoking. Emergency Management of Mrs. Middleton Mrs Amelia presents with a range of symptoms which are however not conclusive and hence would not lend her condition to a specific treatment. Difficulty in speaking would present issues with the diagnosis of her condition given that she is unable to fully explain her condition to medical personnel. The instance of headache would suggest that subarachnoid hemorrhage and hence this supports Ischemic hemorrhage diagnosis. Blood pressure of 200/110 is quite high while the pulse is irregular and this suggests this is probably due to the atrial fibrillation (Bots, Elwood & Nikitin, 2012). Given that she has high levels of sugar this could also result in the high blood pressure and this ought to be dealt with. A history of gastro intestinal bleeding and hemorrhoids muddies the diagnosis and hence more tests need to be carried out (Broderick, 2013). In the first 24 hours of her stay in the medical facility I would have to establish what type of CVA Mrs. Middleton is suffering from. Given the overwhelming evidence in support of ischemic hemorrhage I would immediately start her on medication for ischemic CVA. However I would also make use of drugs for hemorrhagic CVA. It will be critical for Mrs. Middleton to receive both sets of drugs before the final tests are done to determine what type of CVA she has. In order to reduce her blood pressure she will be taken off the sertraline (Bendok, 2012). Her headache may be dealt with through administration of painkillers. I will have to determine the type of diabetes medications she is on and how this may have resulted into her CVA. Rectinol will have to be stopped in order to bring down and regularize her pulse and reduce blood pressure since it causes blood to be thin. Since she cannot respond verbally it would be important to have close family members in attendance to assist in communication of any issues that may arise with the new medications and to give a better history (Stroke, 2009). Given her history of depression it would be advisable to have family members around her which is one of the precipitating factors of hypertension. Thrombolysis Mrs. Middleton condition certainly calls for treatment through thrombolysis. The patient has a history of myocardial infarction, acute limb ischemia and stroke like symptoms. The CT scan and ECG have established that the patient is not suffering from hemorrhagic CVA which allows the health care practitioner to administer thrombolytic treatment. She has difficulties using her right arm and also difficulty speaking. Her father died of myocardial infarct and her history of hemorrhoids predisposes her to ischemic CVA as opposed to hemorrhagic CVA. While she has headaches they are not migraines and therefore the headache symptom is not conclusive evidence of hemorrhagic CVA (Miller et al, 2013). The most commonly used agents for thrombolysis are streptokinase, urokinase, and tissue plasminogen activator. Streptokinase is derived from group C B hemolytic streptococci. It acts by forming a non covalent SK plasminogen activator complex through activation of adjacent plasminogen (Wolf, Abbott & Kannel, 2011). The medical practitioner must take into consideration that retreatment may be difficult since administration results in the production of antibodies. Urokinase which is non fibrin specific is obtained from cultured human cells and acts by activating plasminogen by acting as an enzyme. Through enzyme action it activates plasminogen (Saver et al, 2011). Reteplase is mad eup of 355 of the 527 amino acids which also includes krinle 2 and contains non glycosylated deletion mutein of Tpa. Tecneteplase is different from alteplase since it has 527 amino acids as opposed to 521. Acute myocardial infarction calls for the use of streptokinase and the three tPA (Alteplase, Tenecteplase, and Reteplase). Clotted AV fistula and shunts make use of urokinase, acute ischemic stroke uses the tPA (Alteplase). Acute deep venous thrombosis makes use of streptokinase while acute pulmonary embolism is treated with streptokinase, urokinase and TPA (Alteplase) (Kiely & Nicholas, 2010). The circumstances of this case show a higher probability of the CVA being ischemic. The patient also has a history of myocardial infarction and hence this will call, for the use of streptokinase, alteplase, tenecteplase, and reteplase. Streptokinase is potentially allergic but since Mrs. Middleton is not allergic to anything this would not apply (Ansell, 2010). Medication Aspirin is an effective drug for the treatment of cardiovascular diseases but in this instance I would not recommend the doctor to make use of aspirin. Aspirin would interact and neutralize blood thinners such as warfarin and Coumadin which Mrs. Middleton needs. Aspirin is unsafe in this instance since Mrs. Middleton has a history of gastrointestinal bleeding which may be aggravated by the aspirin (Kasner & Gorelick, 2013). She is also suffering from cardiovascular diseases of hypertension, low and irregular pulse and atrial fibrillation which would be exacerbated by the aspirin. Atorvastatin is a suitable drug for decreasing the risk of heart attack and other cardiovascular diseases. Atorvastatin is not a naturally good drug for Ischemic CVA given that it is aimed at reducing the amount of cholesterol and other fatty substances in the blood (Nentwich, Magauran & kahn, 2012). Atorvastatin is more suited to the treatment of hemorrhagic CVA. In this instance CT scans have preliminarily excluded the existence of hemorrhagic CVA and hence Atorvastatin may not be appropriate (Bots, Elwood & Nikitin, 2012). Mrs. Middleton may not need the drug immediately given that she may not be able to exercise or diet in her condition. Her condition calls for a drug which would act on her condition immediately. Carvedilol is one of the medications which will be most effective for Mrs. Middleton’s condition. Carvedilol is a drug which treats heart failure and given Mrs. Middleton’s family history of myocardial infarct Cardevilol in combination with Atorvastatin would serve to complement each other with Cardevilol being a faster drug as compared to Atorvastatin which is more of a preventor of cardiovascular disease (Broderick, 2013). The patient is also suffering from atrial fibrillation which means that she needs cardevilol to treat her heart condition and her high blood pressure. However the medicine is best used in combination with other beta blockers such as Atorvastatin and hence these must be used together (Bendok, 2012). For this reason Mrs. Middleton would be served better through administration of Atorvastatin in the long term plan for the prevention of the risk of CVA. Atrial Fibrillation Atrial fibrillation is a very critical component in this case given that the type of CVA that Mrs. Middleton has is most likely related to her atrial fibrillation. Mrs. Middleton has a family of myocardial infarct which makes the instance of atrial fibrillation even more significant. Atrial fibrillation is a condition in which the heart pumps blood in an irregular manner which results in either high pressure or low pressure (Stroke, 2009). Mrs. Middleton is experiencing irregular heartbeat and pulse which could be a significant factor in her CVA issues. Pooling of blood in the atria due to fibrillation might result in the formation of blood clots which may cause blockage in her brain or in the arteries (Miller et al, 2013). It is also significant to note that the patient did not notice that she had atrial fibrillation and this may have resulted in an exacerbation of her condition. There are various ways in which Mrs. Middleton’s atrial fibrillation may be contained. In this instance the patient has a family history of CVA and this may be the underlying factor. The best course of action would be to seek to reset the rhythm or control the rate or to prevent blood clots. The heart’s rhythm may be reset to normal through cardioversion with drugs (Wolf, Abbott & Kannel, 2011). Using anti-arrhythmics normal sinus rhythm may be restored. This may be done through either oral or intravenous medication (Saver et al, 2011). If atrial fibrillation cannot be converted into normal heart rhythm heart rate control may be achieved through the use of digoxin in combination with calcium channel blockers and blood pressure lowering medications such as angiotensin. Conclusion Mrs. Middleton has a history of CVA, her symptoms show that she is more likely to have ischemic CVA and hence her treatment ought to be in line with this particularly towards preventing or controlling the risk of recurrence through correcting or controlling her atrial fibrillation. Bibliography Ansell BJ. 2000, Cholesterol, stroke risk and stroke prevention. Curr Atheroscler Rep. 2000;2:92–6. Bendok, B. R. 2012. Hemorrhagic and ischemic stroke medical, imaging, surgical and interventional approaches. New York, Thieme. http://elibrary.amc.edu/login?url=http://lib.myilibrary.com/Open.aspx?id=337195&src=1 Bots ML, Elwood PC, Nikitin Y, et al. 2012, Total and HDL cholesterol and risk of stroke. EUROSTROKE: a collaborative study among research in Europe. J Epidemiol Commun Health.;56(supp l1):19–24. Broderick JP. 1994, Intracerebral hemorrhage. In: Gorelick PB, Alter M, eds. Handbook of Neuroepidemiology. New York, NY: Marcel Dekker Inc. Kasner, S. E., & Gorelick, P. B. 2013. Prevention and treatment of ischemic stroke. Philadelphia, Butterworth-Heinemann. Kiely JL, Mc Nicholas WT. 2000, Cardiovascular risk factors in patients with obstructive sleep apnoea syndrome. Eur Respir J;16:128–33. Miller VT, Pearce LA, Feinberg WM, Rothrock JF, Anderson DC, Hart RG. 2013, Differential effect of aspirin versus warfarin on clinical stroke types in patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation Investigators. Neurology.;46:238-240 Nentwich, L. M., Magauran JR, B. G., & kahn, J. H. 2012. Acute Ischemic Stroke, An Issue of Emergency Medicine Clinics. London, Elsevier Health Sciences. http://msvu.eblib.com/patron/FullRecord.aspx?p=1430763. Saver JL et al, Thrombolytic Therapy in Stroke, Medscape, Nov 2011 Stroke: The diagnosis and acute management of stroke and transient ischaemic attacks; NICE Clinical Guideline (July 2009) Wolf PA, Abbott RD, Kannel WB. 2011, Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke ;22:983-988. Read More