ASSIGNMENT OF

ADVANCED NEUROPSYCHOLOGY

CASE STUDY OF ISCHEMIC BRAIN STROKE

Names of group members (PMDACP):

Areeba Khalil Ur Rehman (PMDACP)
Syed Wajahat Ali Naqvi (PMDACP)
Syeda Javeria (PMDACP)

Under the supervision of Dr. Abdul Rab

MRI IMAGE
Nature of case: Ischemic Brain Stroke

Date/month/year: 10-10-2019

History of presenting condition:

Mr. Ahmed Ali is a homeopathic doctor. He was in the clinic and checking his patients. The
weather was turning into fire. It was diagnosed with heat stroke initially. He has a problem with
hypertension and due to heat stroke, his B.P was shoot. Suddenly when he got out of his chair for
giving the medicine, he had an attack of vertigo and he fell on the chair. With the support of
some people hardly he reached his home. When he reached his home he had severe vertigo,
nausea, vomiting, and lack of balance and he was not able to sit, stand and walk. After some
passage of time, his family admitted him to the hospital where he was treated. Initially, he was
treated for a heat stroke after that he was recommended to Dr. Nuzhat Sultana Neurologist at
Memon Hospital. She did an MRI and some lab tests on the patient then finally he was diagnosed
with brain stroke.

Past medical history:

His past medical history was not so good. The patient has had a brain stroke before in 2010 due
to continuously seeing political news regarding the murder and burial of Dr. Imran Farooq. On
the next day, his condition was deteriorating day by day on the base of symptoms such as
vertigo, vomiting, nausea, and loss of body balance. The reason of the second stroke was not too
much clear and defined but some factors are important to mention which may be responsible:

 Hypertension
 High cholesterol level
 Diabetes Mellitus
 Angina Pains (Sometimes)
 Atherosclerosis
 Fat-coated diet
 Financially stressors
 Heat Stroke

Medication History:

After diagnosis he was recommended the medicines:

  Tab Co-Renitec
 Tab Hydralazine 25 mg
 Tab Fortius 10 mg
 Tab Ascard 150 mg
 Tab Serc 16 mg
 Tab Alp 0.5 mg

In the next month, he visited the other neurologist at Dow University Hospital. He changed some
medications:

 Tab Ascard 75 mg
 Tab Norvasc 5 mg
 Tab Nebil 5 mg
 Tab Xplendid 10 mg
 Tab Tanakan 10 mg
 Tab Stageron 25 mg

Social History:

Mr. Ahmed Ali is a senior homeopathic practitioner for the last 30 years. Prior to that, he worked
in the navy but he was interested in doing a job and want to spend his full time in his clinic and
practice. So, he resigned from the Pakistan Navy he totally indulged in his practice. He is not so
much a socialized person. His life is too much stuck in his clinical routine he has no more time
and no more interest to interact with any social gatherings. His leisure activity is watching
politics, talk shows, and watching old films. Usually, he takes a very unsaturated and fatty diet
which is not appropriate for his health. No drug and alcohol history is present.

Hospital Assessment / Representing symptoms:

 Vertigo
 Nausea
 Vomiting
 Severe headache
 Feeling of numbness in head
 Dizziness
 Slightly paralysis effects on tongue
  Numbness in left hand
 Poor muscular coordination
 Loss of body balance, unable to sit, stand or walk
 Loss of memory

Lab Investigations:

CBC:

 HB: 15.0 gm/dl

 RBC: 4.8 × 10 12/L
 HCT: 44%
 MCV: 90 fL
 MCH: 31 pg
 MCHC: 34 gm/dL
 WBC: 8.9 × 10e9/L
 Platelets: 329 × 10 9/L
 Neutrophils: 76 %
 Lymphocytes: 13 %
 Monocytes: 09 %
 Eosinophils: 02 %
 Basophils: 00 %

Electrolytes:

 Sodium: 127 mEq/l

 Potassium: 4.2 mEq/l
 Chloride: 92 mEq/l
 Bicarbonate: 26.0 mEq/l

Biochemistry:

 Urea: 49.6 mg/dl

 HBA1C: 10.19 %
 Creatinine: 1.53 mg/dl
Lipid Profile:

 Triglycerides: 435 mg/dl

 Serum Cholesterol: 134 mg/dl
 HDL Cholesterol: 28.0 mg/dl
 LDL Cholesterol: 48 mg/dl
 VLDL Cholesterol: n/a mg/dl
 Non-HDL Cholesterol: n/a mg/dl

Magnetic Resonance Imaging (MRI):

 Age-related involutional changes are seen in brain parenchyma with prominent ventricles
and sulci
 T2WI/FLAIR hyperintense signals are seen in bilateral periventricular, deep, and
subcortical white matter, representing chronic microvascular ischemic changes of
variable ages.
 T2WI/FLAIR hyperintense foci are also seen in the right middle cerebellar peduncle and
the right cerebellar hemisphere showing patchy post-contrast enhancement. These foci
can be seen secondary to recently established foci of ischemia/small infarction.
 No gross intracranial hemorrhage or mass effect was seen.
 Mucosal thickening is seen in visualized paranasal sinuses with heterogenous signals in
ethmoid sinuses, likely due to sinusitis.

Carotid Doppler Ultrasound:

 No significant plaque in both verbal arteries.

 No narrowing was noted in these arteries

Summary of lab investigations:

The CBC (Complete Blood Count) was not normal. His sodium level was not under the range it
was quit down which is called hyponatremia, which may be associated with heart, kidney, and
liver problems or due to severe vomiting, diarrhea, and dehydration. HBA1C and creatinine were
elevated due to diabetes. His kidney function was slightly affected due to high B.P and glucose
levels in the blood. His triglycerides level (Triglycerides are a type of fat (lipid) found in your
blood. When you eat, your body converts any calories it doesn't need to use right away into
triglycerides. The triglycerides stored in your fat cells) were too high which was 435 mg/dl and
the normal range is 150-200. A high level of Triglycerides is a risk factor to develop plaque and
fatty deposition in the blood arteries which might be the reason for brain stroke.

Now the very significant is the impression and clinical findings of the MRI report.  T2-
hyperintense foci are one of the most frequent findings in cerebral magnetic resonance imaging
(MRI) which represent the lesion in the area of white matter due to abnormal changes on the
account of stroke condition. Due to the stroke on the account of depositing plaque, fat,
thrombosis or embolism or atherosclerosis in which blood supply is suddenly stopped or
reaching insufficient to the brain tissues then there is lesion is generated due to the lack of
oxygen (Ischemia) on which these lesions show up with increased brightness in the MRI. The
overall condition can be called a small brain infarction. Due to the brain infarction right middle
cerebellar peduncle and right cerebellar hemisphere are affected.

Gross Anatomy:

The cerebellum is connected to the brainstem by three cerebellar peduncles: 1) the inferior
cerebellar peduncle (restiform body and juxtrarestiform body) 2) the middle cerebellar peduncle
(brachium pontis), and 3) the superior peduncle (brachium conjunctivum. The wall and lateral
roof of the 4th ventricle are formed by the inner surfaces of the cerebellar peduncles; the rostral
portion by the superior peduncles; and the caudal portions by the inferior peduncles. The middle
cerebellar peduncle is lateral to inferior and superior peduncles and is not directly exposed to the
cavity of the 4th ventricle. The middle cerebellar peduncle can be divided into three portions:
brain stem portion, ventricular portion, and cerebellar portion.

Cerebellar Connection:

The cerebellum is linked to other parts of the brain by numerous efferent and afferent fibers that
are grouped together on each side of the cerebellum in three peduncles (1). Most of the afferent
tracts enter the cerebellum via the inferior and middle cerebellar peduncles. A few enter via the
superior cerebellar peduncle. Afferent fibers are far more numerous than efferent fibers by a ratio
of 40:1. The cortical-Ponto-cerebellar pathway, composed of the corticopontine tract and the
pontocerebellar tract, is a major afferent fiber through the middle cerebellar peduncle. It arises
from the cerebral cortex and enters the ipsilateral pontine nucleus and almost entirely crossed to
the contralateral cerebellum. Olivocerebellar fibers form the largest component of the inferior
cerebellar peduncle. Most efferent tracts of the cerebellum are via the superior cerebellar
peduncle. They mostly arise from the dentate nucleus and decussate at the levels through the
inferior colliculus. Most of the fibers enter the contralateral red nucleus and project to the
cerebral cortex via the thalamus

Symptomatology

Lesions of the cerebellar peduncle result in variable clinical symptoms, ranging from vertigo or
vomiting as the only clinical presentation to facial palsy, ataxia, nystagmus, diplopia, dysphagia,
dysarthria, deafness, contralateral motor weakness, trigeminal sensory loss, dysmetria of the
limb, loss of pain and temperature sense, Horner's syndrome, and "locked-in" syndrome.

Physiology:

The main function of the cerebellar peduncle is to integrate proprioceptive sensory input and
postural maintenance connecting the cerebellum with the spinal cord. The cerebellum is located
behind the top part of the brain stem (where the spinal cord meets the brain) and is made of two
hemispheres (halves). The cerebellum receives information from the sensory systems, spinal
cord, and other parts of the brain and then regulates control of movements. The cerebellum
controls voluntary movements such as:

 walking

 posture

 balance

 coordination

 eye movements

 speech

This control results in smooth and balanced muscular activity. The cerebellum is also important
for learning motor behaviors. Damage to the cerebellum, while not causing paralysis or
intellectual impairment, might lead to:

 Lack of balance

 Slower movements

 Tremors (shaking)
WHAT IS BRAIN STROKE?

Damage to the part of the brain caused by interruption to its blood supply (either by a thrombus
or embolus) leakage of blood outside of vessel walls is known as stroke.

A stroke occurs when a blood vessel in the brain ruptures and bleeds, or when there’s a blockage
in the blood supply to the brain. The rupture or blockage prevents blood and oxygen from
reaching the brain’s tissues.

According to the Centers for Disease Control and Prevention (CDC) Trusted Source, stroke is a
leading cause of death in the United States. Every year, more than 795,000 U.S. people have a
stroke.

Without oxygen, brain cells and tissue become damaged and begin to die within minutes.

 15 million worldwide have a stroke

 Incident is about 1.25 times greater for males than females
 Risk rate among people age 65 years and older

IMPORTANT TERMS:

Atherosclerosis: begins with damage to the inner wall of the artery caused by high blood
pressure, diabetes, smoking, and elevated “bad” cholesterol.

Ischemic stroke: involves a blockage caused by either a clot or plaque in the artery. The
symptoms and complications of ischemic stroke can last longer than those of a TIA, or may
become permanent
Thrombosis: A thrombotic stroke is a type of ischemic stroke. This means a part of the brain gets
injured because the artery that normally supplies blood to it gets blocked, so blood flow is
reduced or stops completely.

Embolism: The other type of ischemic stroke is an embolic stroke. In this case, the blood clot,
called an embolus, forms in another part of the body. It moves with your blood to an artery in
your brain where it gets stuck and blocks off the artery.

Brain infarction: Also called ischemic stroke, a cerebral infarction occurs as a result
of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack
of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can
cause parts of the brain to die off.

Hemorrhage: The hemorrhage is defined as the escape of blood from the vessels, a massive
accumulation of blood within the brain is called Hematoma.

SYMPTOMS:

It is characterized by the impairment of the sensation, movement, or function controlled by a

damaged part of the brain. The loss of blood flow to the brain damages tissues within the brain.
Symptoms of a stroke show up in the body parts controlled by the damaged areas of the brain.

The sooner a person having a stroke gets care, the better their outcome is likely to be. For this
reason, it’s helpful to know the signs of a stroke so you can act quickly. Stroke symptoms can
include:

 Paralysis:
 numbness or weakness in the arm, face, and leg, especially on one side of the body
 trouble speaking or understanding others slurred speech confusion
 disorientation
 lack of responsiveness to sudden behavioral changes
 especially increased agitation vision problems, such as trouble seeing in one or both eyes
with vision blackened or blurred, or double vision
 trouble walking loss of balance or coordination
 dizziness
 severe, sudden headache with an unknown cause seizures nausea, or vomiting
 TYPES OF BRAIN STROKE:

Ischemic (Blocking) stroke:

It is the most common type and results when blood clots or impairs blood flow, depriving the
brain of essential oxygen and nutrients. During an ischemic stroke, the arteries supplying blood
to the brain narrow or become blocked. Blood clots or severely reduced blow flow to the brain
causes these blockages. Pieces of plaque breaking off and blocking a blood vessel can also cause
them.

There are two types of blockages Trusted Source that can lead to ischemic stroke: cerebral
embolism and cerebral thrombosis.

A cerebral embolism (often referred to as embolic stroke) occurs when a blood clot forms in
another part of the body often the heart or arteries in the upper chest and neck and moves through
the bloodstream until it hits an artery too narrow to let it pass. The clot gets stuck, stops the flow
of blood, and causes a stroke.

Cerebral thrombosis (often referred to as thrombotic stroke) occurs when a blood clot develops
at the fatty plaque within the blood vessel

 Majority cases are of ischemic stroke about 85%

 Clot in the blood vessel supplying to the brain can obstruct the blood flow to the brain.
 The clot can travel from the heart due to irregular heartbeat and atrial fibrillation
 Within the first few hours bursting thrombolytic medication can help, others medication
includes Aspirin

Hemorrhagic (Bleeding) Stroke:

A hemorrhagic stroke is when blood from an artery begins bleeding into the brain. This happens
when weakened blood vessels burst and bleed into the surrounding brain.

A hemorrhagic stroke happens when an artery in the brain breaks open or leaks blood. The blood
from that artery creates excess pressure in the skull and swells the brain, damaging brain cells,
and tissues. The two types of hemorrhagic strokes are intracerebral and subarachnoid:

An intracerebral hemorrhagic stroke is the most common type of hemorrhagic stroke. It happens
when the tissues surrounding the brain fill with blood after an artery burst.
A subarachnoid hemorrhagic stroke is less common. It causes bleeding in the area between the
brain and the tissues that cover it.

 Minority cases 15%

 Blood in the brain leads to swelling
 In some cases, it requires surgery

TIA (Transient ischemic attack):

A transient ischemic attack (TIA) is a brief episode during which parts of the brain do not
receive enough blood. Because the blood supply is restored quickly, brain tissue does not die as
it does in a stroke. These attacks are often early warning signs of a stroke, however.

RISK FACTORS FOR STROKE:

Certain risk factors make you more susceptible to stroke. According to the National Heart, Lung,
and Blood Institute Trusted Source, risk factors for stroke include:

Diet: An unbalanced diet can increase the risk of stroke. This type of diet is high in (salt,
saturated fats. trans fats etc.)
Heavy alcohol use
Tobacco use
Personal background
Health history
High blood pressure
Smoking
Heart disease
Diabetes
Cholesterol imbalance:
Physical inactivity and obesity

Heavy alcohol use: The risk of stroke also increases with heavy alcohol use. If you drink, drink
in moderation. This means no more than one drink a day for women, and no more than two
drinks a day for men. Heavy alcohol use can raise blood pressure levels. It can also raise
triglyceride levels, which can cause atherosclerosis. This is plaque buildup in the arteries that
narrows blood vessels.
Tobacco use: Using tobacco in any form also raises the risk of stroke, since it can damage the
blood vessels and heart. Nicotine also raises blood pressure.

Personal background: There are some risk factors for stroke you can’t control, such as:

 Family history: Stroke risk is higher in some families because of genetic health factors,
such as high blood pressure.
 Sex: According to the CDC Trusted Source, while both women and men can have
strokes, they’re more common in women than in men in all age groups.
 Age: The older you are, the more likely you are to have a stroke.
 Race and ethnicity: African Americans, Alaska Natives, and American Indians are more
likely to have a stroke than other racial groups.

Health history: Certain medical conditions are linked to stroke risk. These include:

 a previous stroke or TIA

 high blood pressure
 high cholesterol
 carrying too much excess weight
 heart disorders, such as coronary artery disease
 heart valve defects
 enlarged heart chambers and irregular heartbeats
 sickle cell disease
 diabetes
 blood clotting disorder
 patent foramen ovale (PFO)

High blood pressure or hypertension: 

Hypertension is by far the most potent risk factor for stroke. Hypertension causes a two-to four-
fold increase in the risk of stroke before age 80.  If your blood pressure is high, you and your
doctor need to work out an individual strategy to bring it down to the normal range. Some ways
that work: Maintain proper weight. Avoid drugs known to raise blood pressure. Eat right:  cut
down on salt and eat fruits and vegetables to increase potassium in your diet. Exercise more.
Your doctor may prescribe medicines that help lower blood pressure. Controlling blood pressure
will also help you avoid heart disease, diabetes, and kidney failure.
Cigarette smoking: 

Cigarette smoking causes about a two-fold increase in the risk of ischemic stroke and up to a
four-fold increase in the risk of hemorrhagic stroke.  It has been linked to the buildup of fatty
substances (atherosclerosis) in the carotid artery, the main neck artery supplying blood to the
brain. Blockage of this artery is the leading cause of stroke in Americans. Also, nicotine raises
blood pressure; carbon monoxide from smoking reduces the amount of oxygen your blood can
carry to the brain, and cigarette smoke makes your blood thicker and more likely to clot.
Smoking also promotes aneurysm formation. Your doctor can recommend programs and
medications that may help you quit smoking. By quitting, at any age, you also reduce your risk
of lung disease, heart disease, and a number of cancers including lung cancer.

Heart disease: 

Common heart disorders such as coronary artery disease, valve defects, irregular heartbeat (atrial
fibrillation), and enlargement of one of the heart's chambers can result in blood clots that may
break loose and block vessels in or leading to the brain. Atrial fibrillation which is more
prevalent in older people is responsible for one in four strokes after age 80 and is associated with
higher mortality and disability. The most common blood vessel disease is atherosclerosis.
Hypertension promotes atherosclerosis and causes mechanical damage to the walls of blood
vessels. Your doctor will treat your heart disease and may also prescribe medication, such as
aspirin, to help prevent the formation of clots. Your doctor may recommend surgery to clean out
a clogged neck artery if you match a particular risk profile. If you are over 50, NINDS scientists
believe you and your doctor should make a decision about aspirin therapy. A doctor can evaluate
your risk factors and help you decide if you will benefit from aspirin or other blood-thinning
therapy.

Diabetes: 

In terms of stroke and cardiovascular disease, having diabetes is the equivalent of aging 15 years.
You may think this disorder affects only the body's ability to use sugar, or glucose. But it also
causes destructive changes in the blood vessels throughout the body, including the brain. Also, if
blood glucose levels are high at the time of a stroke, then brain damage is usually more severe
and extensive than when blood glucose is well-controlled. Hypertension is common among
diabetics and accounts for much of their increased stroke risk. Treating diabetes can delay the
onset of complications that increase the risk of stroke.
Cholesterol imbalance:

Low-density lipoprotein cholesterol (LDL) carries cholesterol (a fatty substance) through the
blood and delivers it to cells.  Excess LDL can cause cholesterol to build up in blood vessels,
leading to atherosclerosis.  Atherosclerosis is the major cause of blood vessel narrowing, leading
to both heart attack and stroke.

 Physical In Activity and Obesity: 

Obesity and inactivity are associated with hypertension, diabetes, and heart disease.  Waist
circumference to hip circumference ratio equal to or above the mid-value for the population
increases the risk of ischemic stroke three-fold.
 CONSTRUCTING MANAGEMENT PLAN

1. Use of clot bursting medicines:

Clot-busting medicines are applied to the patient to remove the immediate clot from the brain.
This use of "clot-busting" medicine is known as thrombolysis.

Thrombolysis – "clot buster" medicine

Ischemic strokes can often be treated using injections of a medicine called alteplase, which
dissolves blood clots and restores blood flow to the brain.

Alteplase is most effective if started as soon as possible after the stroke occurs – and certainly
within 4.5 hours. It’s not generally recommended if more than 4.5 hours have passed, as it's not
clear how beneficial it is when used after this time. Before alteplase can be used, it's very
important that a brain scan is done to confirm a diagnosis of an ischemic stroke. This is because
the medicine can make the bleeding that occurs in hemorrhagic strokes worse.

Thrombectomy

A small number of severe ischemic strokes can be treated by an emergency procedure called a

thrombectomy. This removes blood clots and helps restore blood flow to the brain.
Thrombectomy is only effective at treating ischemic strokes caused by a blood clot in a large
artery in the brain.  It's most effective when started as soon as possible after a stroke.

The procedure involves inserting a catheter into an artery, often in the groin. A small device is
passed through the catheter into the artery in the brain. The blood clot can then be removed using
the device or through suction. The procedure can be done under local or general anesthetic.

2. Use of medication to control the high level of sugar, blood pressure, and cholesterol

The patient is at a very dangerous risk because his sugar blood pressure and cholesterol are very
much out of control and the increased level of sugar, blood pressure, and cholesterol can be a
source of brain stroke so it should be controlled by hook and by crook. To control all of these,
the patient has been prescribed the medicines with strong instructions for proper and daily usage.

ABC goal:
Keeping control of your “ABCs". A1c, blood pressure, and cholesterol can go a long way to help
prevent heart disease, stroke, and other heart problems when you have type 1 or type 2 diabetes.
And your heart health is very important: You are two to four times more likely to have strokes
and heart disease if you have diabetes. Follow these guidelines for heart-healthy living to meet
your ABC goals. Your doctor may tailor your goals based on your age, blood sugar (also called
glucose) levels, and heart or other diabetes-linked problems you may have.

3. Giving the diet plan:

The diet plays an important role in reducing the level of sugar. The goal of such a patient is to
avoid any surges in blood glucose by maintaining the ideal body weight through proper nutrition.
The diet schedule should be as follows:

Morning: bitter gourd juice 1-2 ounces (40 ml)

Breakfast: skimmed milk (250-400ml) or buttermilk or sprouted gram, Moong, Mithi approx. 50
gm or Fresh Amla juice 50 ml
Lunch: Roti (wheat + gram flour) 25-50 gm, green vegetables 250gm, salad 50gm, Moong 25
gm, curd 150gm + 1 glass buttermilk
Evening: roasted gram 30 gm, vegetable soup or 1 glass buttermilk
Dinner: As in lunch but the use of curd is not advisable at night.

4. Recommendation of physiotherapy:

Due to the brain stroke, his cerebellum is damaged due to which his motor functioning is affected
and impaired. His body balance and posture are disturbed. He cants walk with balance equilibrium
which is called ataxia. In these cases, physiotherapy is very effective to enhance motor functioning.
The brain cannot regenerate any cells lost during the stroke, but physiotherapy can help the brain
reorganize existing cells to compensate for the loss (neuroplasticity).

5. Deep breathing and relaxation exercises for reducing stress:

In the elevation of blood pressure, high level of sugar, and brain stroke cases stress play a crucial
role. With medications and diet plans, it is also necessary to reduce the stress rate which boosts
the pathology in our body, and the history also revealed financial stress which can also be a
contributing factor. To control the stress rate some deep breathing and muscle relaxation
exercises are also recommended to the patient.
6. Counsel the patient to take proper medication and follow the diet plan:

Guidelines are given to the patient during the counseling:

 Medicines play an important role in medical care.

 In addition, the effectiveness of treatment depends on the efficacy of the medication and
patient adherence to the therapeutic regimen.
 Adherence to medications is essential to achieving the best possible pharmacotherapy
outcomes.
 Besides, the Non-adherence to medications results in higher health care costs, more
extended hospitalization, and increased morbidity and mortality.
 Moreover, Patient counseling refers to the process of providing vital information, advice,
and assistance.
 It’s done to help the patients with their medications and ensure they take them properly.
 This also includes essential information about the patient’s illness and lifestyle.
 A patient is advised on whether medications should be taken with or without food, at
bedtime or in the morning, with water, juice, or milk.
 Finally, all this information results in the proper use of medications and the best
therapeutic action.