Case Study Questions

Question 1

1. Aphasia:
   This term refers to a language impairment as an outcome of ischemic damage to two particular brain areas tasked with language processing. In the case of MRS Mary Fenech, decreased blood flow in the left middle cerebral artery abbreviated as MCA territory, reduced by an acute left internal carotid artery (ICA) obstruction, causes ischemia and neuronal injury in dangerous linguistic centres, specifically Wernicke's area (responsible for comprehension of language) and Broca's area (answerable for speech production). Ischemia interrupts neural associations damaging the capacity to develop and articulate words logically, namely expressive aphasia, and comprehending spoken and written language known as receptive aphasia (Feske, 2021). The subsequent discrepancies in language communication initiate from the conceded blood supply to such areas, influencing neural networks.
2. Right-sided facial droop with right-sided weakness in upper and lower limbs:
   The right-sided facial droop and limb weakness is a result of the interruption of motor pathways because of ischemic damage in the left hemisphere as a result of ICA occlusion. The left hemisphere directs voluntary motor functions for the right side of the body. Decreased blood flow in the left MCA territory negotiates the integration of motor neurons and their connections causing hemiparesis. The facial nerve nucleus is also impacted as an outcome of the facial drop on the right side (Mendelson and Prabhakaran, 2021). The insufficient nutrients and oxygen from diminished blood stimulate triggering an energy deficiency, damaging the function of neurons comprised in motor control. The produced weakness and facial droop are indicators of neural destruction as a result of the ischemic abuse, specifically in the corticospinal tract and the facial motor nucleus.

Question 2

Category 3: Reperfusion interventions

1. Thrombolysis with Alteplase IV:
   Rationale: Thrombolysis with Alteplase, which is a tissue plasminogen activator (iPA), is a time-sensitive involvement that places a central role in reperfusion. Alteplase restores cerebral perfusion and decreases chemical damage by starting the breakdown of the following cloth blocking the blood vessel. The supervising of Alteplase in the context of the therapeutic window of 4.5 hours from symptom onset (as per the guidelines of stroke management) has been dedicated to majorly enhancing functional outcomes and decreasing disability (Saini et al., 2021). Clinical trials like the ECASS III trial depicted that administering Alteplase enhances the probability of completing independent functional results when compared to a Placebo. Therefore, it acts as a formal logical medium to reperinfuse the ischemic brain tissue probably combating the extent of deficits neurologically.
2. Endovascular Clot Retrieval (ECR):
   Rationale: ECR also popular as mechanical thrombectomy, is an improvised strategy for reperfusion incorporated in cases of large vessel occlusions, such as acute left ICA occlusion of MRS Fenech. ECR includes the utilisation of specialized catheters and devices for physically removing the obstructing clot from the cerebral vasculature. This phenomenon enables quick Restoration of blood flow that is specifically advantageous in instances where intravenous thrombolysis may be unsuccessful or contraindicated. The beneficial influence of ECR on patient results is documented appropriately. The Landmark trials like MR CLEAN, DAWN and HERMES depicted a major enhancement in functional independence and decreased rates of mortality in patience undergoing ECR as compared to those getting standard medical therapy alone. The success of ECR depends on its ability to restore perfusion quickly to the impacted brain tissue, protecting the neurones and reducing neurological deficits to the least.

Question 3

Ensure airway patency and oxygenation.

Continuous cardiac monitoring and 12-lead ECG monitoring.

Prepare for endovascular clot retrieval (ECR).

Administer Alteplase IV within the therapeutic window.

Monitor neurological status and Glasgow Coma Scale hourly.

Question 4

1. Maintain Nil by Mouth:
   Rationale: Mrs Mary Fenech like ischemic stroke patients are exposed to dysphagia and aspiration because of damaged swelling reflexes. Nil by mouth abbreviated as NPO status is important to avoid the aspiration of oral secretions or injected material within the respiratory tract combating the probability of aspiration pneumonia that can intensify respiratory problems and increases the complications. NPO status gives time for a detailed swallowing evaluation by speech pathology for determining the ability of the patient to safely swallow and sharing that oral intake can be continued without risking respiratory health.
2. Monitor for Haematemesis, Melaena, and Haematuria
   Rationale: Monitoring for the science of bleeding such as vomiting blood, haematuria (blood in urine) and melaena (tarry, dark stools) is crucial because of the usage of anticoagulant therapy namely heparin and blockage dissolving impacts of Alteplase (Goyal et al., 2020). Heparin leads to intensifying the risk of bleeding and fibrinolytic action of Alteplase might predispose the bleeding complications to the patient. Early detection of bleeding allows for intervention adjustment to anti-coagulation therapy and probable reversal strategies listening to the risk of hemorrhagic complications and patient safety optimisation.
3. Insertion of a Nasogastric Tube:
   Rationale: Placing a nasogastric tube acts for various purposes for ischemic stroke management. It also decomposes the stomach combating the risk of aspiration by avoiding the gastric contents accumulation. Such tubes also give a path of aspiration by avoiding the accumulation of gastric contents. The nasogastric tube also gives a path for medication administration, confirming the timely delivery of important medications such as neuroprotective agents or antiplatelets. In addition to this, it promotes enteral nutrition, combating the nutritional requirements of the patient where is preventing the risk related to oral intake, taking into account the possible swallowing difficulties.
4. Collaborating with the Family:
   Rationale: Participation by the family of the patient is essential for detailed and patient-centred care. Family members can give important insights into the baseline health, unique needs and preferences of the patient. Collaborative decision-making improves the interventions plan and execution, promoting a holistic approach that signatures with the values and goals of the patients. Additionally, family involvement gives emotional support reducing the anxiety of the patient and adding to the overall well-being.
5. Healthcare Team Collaborations:
   Rationale: Ischemic stroke management makes it essential to have a multi-disciplinary approach to addressing the complicated requirements of patients. Partnering with a Healthcare team inclusive of radiologists, neurologists, physicians and speech pathologists confirms evidence-motivated and comprehensive care (Tuo et al., 2022). Each team member comes with dedicated executives to various aspects of patient care outcoming in optimised clinical outcomes and promoting timely interventions such as endovascular blockage retrieval or thrombolysis.

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