Pathophysiology and pharmacology of cerebrovascular accident: A case study

This case study discusses the pathophysiology and pharmacology of cerebrovascular accident, including risk factors and treatment options. It also highlights the importance of nursing assessment in providing holistic care to patients.

Running head: CASE STUDY
Pathophysiology and pharmacology
Name of the Student
Name of the University
Author Note

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Introduction
A paramedic professional is a highly skilled and trained medical professional having the
necessary education to conduct the major responsibilities of a physician. The primary role of a
paramedic is associated with examination, evaluation, and treatment of patients with necessary
medications and equipment that are usually found in hospital emergency departments. Nursing
assessment refers to the process that facilitates the gathering of relevant clinical information
about the psychological, physical, sociological, and spiritual condition of a client, and is usually
conducted by registered or licensed nursing professionals (Giger, 2016). Owing to the fact that
such nursing assessments are an integral to the first phase of providing nursing care to a service
user, it should be considered as the foundation of a care plan. Thus, the primary aim of assessing
a patient in a holistic manner is to get a sound understanding of the underlying conditions and
formulating a care plan in accordance to the patient needs.
Cerebrovascular accident
Cerebrovascular accident (CVA), commonly referred to as stroke refers to the medical
condition where there occurs poor flow of blood to the human brain, thereby resulting in death of
the brain cells (Kim, Baumgartner & Clements, 2013). The case study is about a septuagenarian,
Mr. Sam Kwon, who had been admitted by a paramedic professional in the hospital. Some of his
presenting complaints were hemiparalysis in the right side of the body, facial drooping and
aphasia. Furthermore, the patient’s medical history suggested previous instances of hypertension,
congestive heart failure, besides diagnosis of type 2 diabetes. The patient was found to be under
the prescribed medication of oral hypoglycaemic agents and was an active smoker for not less
than 40 years. Some of his signs and symptoms, following admission to the hospital were early

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oedema, CVA in the left part of the brain, homonymous hemianopia, and increased blood sugar
levels. Thus, it can be suggested that the CVA that the client is suffering from is a neurological
deficit associated with a cerebrovascular reason that is found to persist or more than 24 hours
(WHO, 2014). The condition most often gets interrupted within 24 hours, and subsequently
results in death of the affected people. Therefore, an analysis of the initial signs and symptoms
indicate that Mr. Kwon is at a high risk of death and other co-morbidities, if not treated properly.
Pathophysiology
Ischemic stroke is generally found to occur due to lack of adequate blood supply to
different regions of the brain, thereby resulting in an initiation of the major ischemic cascade.
The ischemic cascade commonly refers to a sequence of biochemical reactions that are triggered
in the brain and different aerobic tissues, following an ischemia attack (Trachtenberg et al.,
2015). This is mostly secondary to all forms of CVA, and cardiac arrest. This leads to death of
most ischemic neurons, due to chemical activation. Following disruption of blood supply for 60-
90 seconds, the neuronal tissues usually cease to perform their normal functions (Mastoris et al.,
2014). Deprivation of the much needed oxygen for more than three hours leads to the onset of
infarction and/or tissue death. The reactive oxygen species (ROS) are found to play an important
role in influencing the cerebral vascular tone. Superoxide, the anion has been found to influence
either a constriction or a dilation of the cerebral arteries (Brown & Griendling, 2015).
Furthermore, the ischemic CVA is also caused due to thrombosis, focal hypoperfusion
and embolism. The fact that the client has hypertension can be attributed as a major contributing
factor to the condition. Uncontrolled elevated blood pressure results in the onset of stroke by
weakening and damaging the blood vessels that innervate the brain, thereby leading to a
narrowing of the vessels (Wu et al., 2015). This eventually contributes to a leak or rupture.

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Higher blood pressure of the client might have also resulted in formation of blood clots in the
major blood vessels, the arteries, thereby leading to a blockage to the flow of blood in the brain,
and potentially causing a cerebrovascular accident. The client was an active smoker for more
than 40 years. This is a major risk factor that contributed to the onset of CVA. There is mounting
evidence to establish the fact that smoking is responsible for a double increase in the risks of
stroke. Smokers are at an increased likelihood of developing hypertension that might have
contributed to a damage in the arteries. Continuous inhalation of cigarette smoke result in
making the bloodstream stickier, which increases the chances of clot formation, thereby blocking
its flow to the heart and brain. Furthermore, smoking is also related to an increase in the
accumulation of plaques in the blood vessels, thereby causing narrowing and thickening of the
vessels (Peters, Huxley & Woodward, 2013).
Congestive heart failure (CHF) that was reported by the patient is also related to an
increased risk of formation of thrombus and thereby elevates the risks of stroke manifold.
Increased mortality and poor health outcomes are some of the major manifestations of congestive
heart failure, concomitant with CVA. Furthermore, the fact that Mr. Kwon had been diagnosed
with type 2 diabetes mellitus can also be accredited as a major risk factor that might have
triggered the onset of stroke. Diabetes mellitus creates an impact on the ability of the body to
produce insulin or its proper usage. Owing to the fact that the hormone insulin is important in
glucose absorption from the bloodstream into the cells, patients with diabetes often contain more
amount of blood sugar levels (Patel, 2016). Over time, the accumulation of sugar in the
bloodstream adds to the accretion of fat deposits and/or clots inside the vessels supplying blood
to the brain and the neck. Commonly known as atherosclerosis, this condition is another
pathophysiological indication of the CVA.

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Pharmacology
Thrombolytic therapy has been identified as a mainstay treatment for cerebrovascular
accidents. Thrombolytic drugs refer to chemical agents that have the capability of dissolving
thrombus and reopening a vein or an artery. These agents are commonly used for the treatment
of stroke, deep vein thrombosis, pulmonary embolism, occlusion, and heart attack. The
thrombolytic agents are principally serine proteases that have the capability of digesting protein
and converting plasminogen to plasmin. The proteolytic enzyme plasmin helps in breaking the
cross-links that are present in the fibrin molecules, thereby restricting the damage to the blood
vessels that have been caused due to presence of blockage in the arteries. This action
subsequently results in naming the agents as fibrinolytic drugs and/or plasminogen activators
(Marti et al., 2014). The principal aim of the thrombolysis therapy in treating the patient having
suffered CVA would be directed towards recanalising the occuled intracranial arteries.
Recanalising the arteries has been identified as an essential predictor of CVA related outcomes,
owing to the fact that restoring the regional cerebral perfusion is a major step towards recovering
the ischemic tissues (Hafez et al., 2014). Some of the major thrombolytic agents that can be
prescribed to the client include alteplase (Activase or t-PA), reteplase (Retavase or r-PA),
prourokinase, urokinase (Abbokinase), streptokinase, and anisoylated purified streptokinase
activator complex (APSAC). Alteplase administered at a dosage of 0.9 mg/kg over a period of
one hour might prove effective in treating the CVA (Emberson et al., 2014).
Routine administration of antiplatelet drugs is another major pharmacological
intervention that can be used for treatment of CVA. Also referred to as antiaggregants, the drugs
belong to a class of molecules that are responsible for reducing platelet aggregation, thus
inhibiting thrombus formation. These class of drugs have been found to be tremendously

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effective in bringing about an improvement of arterial circulation, under conditions where
anticoagulants have been found to exert little or no effect. Treatment and prevention of arterial
thrombosis is crucial in reducing the damaging effects of CVA. The antiplatelet drugs are able to
change the platelet activation at the region that has suffered vascular damage (Mauri et al.,
2014). Triflusal or aspirin has the potential of reversibly inhibiting the COX enzyme, thus
leading to a reduction in the production of thromboxane or TXA2, an effective vasoconstrictor
that is able to reduce the levels of cyclic AMP and subsequently initiate the reaction of platelet
release (Feres et al., 2013).
Furthermore, clopidogrel and dipyridamole are other antiplatelet agents that would prove
beneficial in treatment of Mr. Kwon. Clopidogrel, also referred to as a pro-drug follows a two-
step process of activation. The first activation step is triggered by CYP2C19, CYP1A2 and
CYP2B6, followed by CYP2C19, CYP2C9, CYP2B6 and CYP3A triggering the second step.
Following the binding of the active metabolite in an irreversible manner, the P2Y12 subtype
of ADP receptor gets inhibited, which is an essential step in platelet activation and fibrin
crosslinking (Qureshi & Hobson, 2013). Apart from the ongoing medications, there is a need to
administer thiazide-diuretics that will put a check on his hypertension by inhibiting sodium and
chloride reabsorption from the DCT by blocking thiazide-sensitive Na+-Cl− symporters (Musini
et al., 2014).
Conclusion
To conclude, the two main kinds of CVA are namely, ischemic stroke due to inadequate
flow of blood, and haemorrhagic stroke that occurs due to internal bleeding. The two conditions
lead to disruption of function in portions of the brain. The cerebrovascular accident that the
patient is suffering from can be accredited to a range of risk factors such as, hypertension,

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smoking and type 2 diabetes mellitus. All of these factors increased his susceptibility to the
health condition. Build-up of clots in the arteries that supplied blood to the brain led to a
narrowing of the blood vessels, and subsequent blockage of blood flow that increased the
likelihood of suffering a stroke. Thus, the administration of antiplatelet drugs and thrombolytic
agents are the major treatment strategies that should be adopted for dissolving the blood clots in
the arteries and reducing mortality risks.

7CASE STUDY
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