Question

Mrs. Giammo is a 59-year-old woman who was brought to the emergency department by her husband. Mr. Giammo noticed that all of a sudden his wife "was slurring her speech and her face was drooping on one side." Mrs. Giammo told her husband that she felt some numbness on the right side of her face and in her right arm. Mr. Giammo was afraid his wife was having a stroke so he brought her to the hospital.

Case Study

In the emergency department, Mrs. Giammo is alert and oriented. Her vital signs are temperature 98.28F (36.78C), blood pressure 148/97, pulse 81, and respiratory rate 14. An electrocardiogram (ECG, EKG) monitor shows a normal sinus rhythm. Mrs. Giammo is still complaining of "numbness" of the right side of her face and down her right arm. Her mouth is noted to divert to the right side with a slight facial droop when she smiles. Her speech is clear. She is able to move all of her extremities and follow commands. Her pupils are round, equal, and reactive to light (4 mm to 2 mm) and accommodation. There is no nystagmus noted. Her right hand grasp is weaker than her left. Mrs. Giammo does not have a headache and denies any nausea, vomiting, chest pain, diaphoresis, or visual complaints. She is not experiencing any significant weakness, has a steady gait, and is able to swallow without difficulty. Laboratory blood test results are as follows: white blood cell count (WBC) 8,000 cells/mm3, hemoglobin (Hgb) 14 g/dL, hematocrit (Hct) 44%, platelets = 294,000 mm3, erythrocyte sedimentation rate (ESR) 15 mm/hr, prothrombin time (PT) 12.9 seconds, international normalized ratio (INR) 1.10, sodium (Na2+) 149 mEq/L, potassium (K+) 4.5 mEq/L, glucose 105 mg/dL, calcium (Ca2+) 9.5 mg/dL, blood urea nitrogen (BUN) 15 mg/dL, and creatinine (creat) 0.8 mg/dL. A head computed tomography (CT) scan is done which shows no acute intracranial change and a magnetic resonance imagery (MRI) is within normal limits. Mrs. Giammo is started on an intravenous heparin drip of 25,000 units in 500 cc of D5W at 18 mL per hour (900 units per hour). Mrs. Giammo is admitted for a neurology evaluation, magnetic resonance angiography (MRA) of the brain, a fasting serum cholesterol, and blood pressure monitoring. Upon admission to the nursing unit, her symptoms have resolved. There is no facial asymmetry and her complaint of numbness has subsided.

Questions

The neurologist's consult report states, "At no time during the episode of numbness did the client ever develop any scotoma, amaurosis, ataxia, or diplopia." Explain what these terms mean.

Discuss the pathophysiology of a transient ischemic attack (TIA). Include in your discussion what causes a TIA and the natural course of a TIA.

Mrs. Giammo asks, "How is what I had different from a stroke?" Provide a simple explanation of how a transient ischemic attack (TIA) differs from a cerebrovascular accident (CVA, stroke).

Discuss the defining characteristics of a transient ischemic attack (TIA).

Answer 1

SCOTOMA

It is n irruption of break in the visual fied causes partial loss of vision or blind spot which is caused by multiple sclerosis damage to the nerve fiber in the retina due to hypertension,toxic substances such asa methyl alcohol,nutritional deficiencise and vascular blockagein retina or inthe optic nerve.

AMAUROSIS

It is a partial or total blindness without visible changes in the eye due to lack of blood flow to the retina.it may be occured due to increasing age,alcohol use,cocaine use,diabetes etc.

ATAXIA

It is the impaired balance or incoordination due to due to damage to the brain,nerve or muscles.It may lead to difficulty with speech,eye movements and swallowing.

DIPLOPIA

It is also known as double vision or the person can see a double image where there should be one.The two images can be sise by side or on top of one another or both. It can occur due to neurological or neoplastic causes such as progressive subnuclear palsy,brain tumor etc.

TIA(Transient Ischemic Attack)

• The risk natural causes of TIA is age greater than 55,sex, family history ,genetics and race.Which may also can occur due to smoking,hypertension,diabetes mellitus,hyperlipidimia and the narrowing of the carotid artery.
• TIA can occur due to the cholestrol containing fatty deposits called plaques(atherosclerosis) in an artery or in its branches that supplies oxygen and nutrients to the brain.
• This atherosclerosis will lead to intra cranial or extra cranial atherosclerosis, which means this fatty deposition in the artery will be causing the narrowng of the artery will lead to decreased blood supply to the brain or artery embolism.
• so the blood flow to the brain will become<25ml/100/min which means ineffective cerebral tissue perfusion
• So that neurons will be unable to maintain aerobic respiration which will initiates the mitochondria to switch to aerobic respiration.
• Ithis causes low ATP which means energy failure, intracellular calcium level is increases.
• It may cause the breakdown of the cell membranes and proteins and the formation of the radicals,which can lead to cell injury and TIA

Difference between TIA and Stroke

TIA is a mini stroke or which is a warning sign of stroke due to the temporary block of the cerebral artery and may lead to the temporary reduced brain funtion in which the symptoms can be occur suddenly but lasts for lest than 5 minutes.Where the stroke is a medical emergency and the fifth leading cause of death, may occur due to the complete blockage of the artery may lead to the death of the cells of affected area.

Characteristics of TIA

• ​​​​​​​Temporarly reduction of the cerebral blood flow.
• The symptoms lasts for 1 minute to 1 hour.
• muscular characteristics such as

1. Difficulty in walking
2. Muscle weakness
3. Probles with coordination
4. Weakness one side of the body

• speech

1. Slurred speech
2. Impaired voice

• visual

1. Blurred vision
2. Vision loss

• facial

1. Muscle weakness
2. Numbness

• Others

1. Difficulty to swallo
2. Mental confusion
3. Reduced sensation to touch
4. Feeling faint
5. Light headedness or Vertigo​​​​​​​