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1. DISORDERS OF THE BRAIN
FUNCTION
By
NN

2. CASE STUDY
Bonnie is a 70-year-old woman who lives alone. One evening, she felt light-headed and
dizzy. When her head began to ache, she decided to take an analgesic and go to bed
early. The following morning, upon awakening, she was unable to move the bed sheets
with her right arm. At this point she was experiencing tingling sensations in her limbs,
and she had difficulty keeping her balance. She dialed 911 for help, and by the time the
ambulance arrived, she was confused and unable to articulate her words although she
knew what information he was asking of her. In the hospital, she was examined and
treated for ischemic stroke.

3. BRAIN ANATOMY
 Cerebrum- Has two
hemispheres, Each has a
cortex of four lobes:
 Frontal-movement, executive
function
 Parietal Lobe-sensory information
 Temporal lobe- hearing, memory,
face recognition
 Occipital lobe-vision
 Brain Stem- Heart Rate, Blood
Pressure, breathing, GI
function
(Norris, T. L. 2019, P.
433)

4. BLOOD SUPPLY TO THE BRAIN
(Norris, T. L. 2019, PP.

5. WHAT IS ISCHEMIC STROKE?
Ischemic Stroke- interruption of blood flow in cerebral
vessel, caused by cerebrovascular obstruction by
thrombosis or emboli, accounts 87% of all stroke.
Hemorrhagic stroke -another type of stroke.
Types
Transient Ischemic Attack
Temporal disturbance in focal blood flow, reverses
before acute infarction, resolves in 24 hours.
Thrombotic Stroke
Plaques found at arterial burfication, older people,
occurs in atherosclerotic blood vessels, larger vessel of
the brain, cortex-aphasia or neglect, amaurosis fugax
Lacunar Stroke-
artery wall become narrow and thick, deeper
noncortisol part of the brain or brain stem-embolism,
hypertension, small valve occlusive disease,
hematologic abnormalities, small intracerebral
hemorrhages, vasospasm
Embolic Stroke
(Norris, T. L. 2019,
P.488)

6. ETIOLOGY/ MECHANISM OF ISCHEMIC
STROKEIschemic Stroke occurs in two major ways:
Endothelial Cell Dysfunction- damages to the
endothelium
causes irritation to tunica intima(slippery lining of
the artery) e.g. toxin from tobacco, results in
atherosclerotic site-plaque build up from fats,
proteins, cholesterol, calcium, and immune cells at
atherosclerotic site and obstruct blood flow.
Plaque- soft cheesy interior and hard outer shell (
fibrous cap) (Norris, T. L. 2019,P. 765)
Embolism
Blood clot breaks from one point and dislodges in
artery downstream due to atherosclerosis or heart
defect (stagnant blood flow), e.g. atrial fibrillation
or heart attack. Clot from left atrium to left ventricle
get direct access to the brain- risk for ischemia,
clot from right atrium goes directly into pulmonary
capillaries (no direct access to brain)- posses no
risk for ischemia, exception with atrial septal defect
(Norris, T. L. 2019 , PP.488,489)

7. BRAIN EDEMA , ISCHEMIC CORE, AND
PENUMBRABrain Edema-Decrease supply of oxygen
and glucose leads to increase Sodium and
Calcium in the cell
Cytotoxic edema- High Sodium absolves
water and causes the cell to swell
 Vasogenic edema- High calcium causes
build up reactive oxygen radicals which then
reacts with lipids membrane of
mitochondrion +lysosomes, damages to mit
+Lyso induces apoptosis and degradative
enzymes, 4-6 hours Immune cells kicks in
and causes inflammation-damages BBB
allowing fluids+ protein to gets into brain (
swelling)
Cingulate/ Uncal Herniation- swelling
pushes unaffected part of the brain ( due to
fixed volume of the skull)
Cerebral Tonsil Herniation –pushes down
Ischemic Penumbra (border zone)- minimally
perfused cell
Factors contributing to survival of neurons
 Large size of blood vessel supplying the area.
 Early recovery from the stroke blockage
 Adequacy of the collateral blood circulation
 Number of branches of supplying vessels
(Boling, B., & Keinath, K. 2018) (Norris, T. L. 2019,

8. CLINICAL FEATURES/SIGNS AND SYMPTOMS
The signs and symptoms (Bonnie in red)
light-headed and dizzy
head began to ache
unable to move the bed sheets with her
right arm.
tingling sensations in her limbs
difficulty keeping her balance
Confused
unable to articulate her words although
she knew what is been ask
Speech with absent or poor grammar
Omission of words or syllables in speech
Poor writing and reading skills
Problematic articulation of words and
sound
Abrupt onset of hemiparesis, monoparesis,
or (rarely) quadriparesis
Hemisensory deficits
Monocular or binocular visual loss
Visual field deficits
Diplopia
Dysarthria
Facial droop
Ataxia
Vertigo (rarely in isolation)
Nystagmus
Aphasia ( receptive vs expressive)
Sudden decrease in level of consciousness
Norris, T. L. 2019,

9. DIFFERENTIAL DIAGNOSIS/ LABORATORY
STUDIES
Differential diagnosis
 dysarthria, dysglossia, dyslalia, dysphonia, Wernicke's
aphasia
Laboratory studies
full medical history,
physical exam
 MRI , head CT scan
 full blood count, lipid profile
Angiography-injecting contrast
Flair sequence MRI- old vs new
Electrocardiogram (ECG, EKG
Carotid ultrasound/Doppler
Diffusion Weight Imaging(DWI)- cerebral ischemia,
identifies
penumbra
(Norris, T. L. 2019, P. 493)

10. COMPLICATION, MANAGEMENT AND
TREATMENT
Management: focus is on restoring blood flow
tissue plasminogen activator (t-PA) (a clot-busting drug)
blood-thinning drugs : aspirin or warfarin(Coumadin)heparin or
clopidogrel (Plavix).
Surgery Intracranial vascular treatments
Balloons to open narrowed blood vessels
Carotid embolectomy
stents to keep blood vessels open
Minimize risk factors such as avoiding smoking, maintaining healthy BP,
Management of diabetes, normal LDL cholesterol levels, Obesity. Age, Family
history of strokes.
Complication: Permanent loss of speech, Severe depression,
death, among others.
(Norris, T. L. 2019,P.
493)

11. CASE RESOLUTION
Bonnie’s stroke led to the damage of the Broca’s area in
the gyrus
The area is responsible for speech especially expression
The broca’s area does not control cognitive and intellectual
properties
Thus bonnie is able to understand the caregiver but cannot
talk
Bonnie had difficulties in expressing herself
Patients are often frustrated since they cannot speak
Lack of speech, poor broken sentences
Expression in writing is also affected.
Without intervention there is progressive loss of speech
Admit and treat the stroke,
Schedule the patient for subsequent visits.

12. PROGNOSIS, CONSULT, REFERRAL, AND
FOLLOW UP
Consult/ referral: speech therapist,
neurologist, psychotherapist
Prognosis: excellent prognosis
determined by underlying condition
Follow up: weekly therapy sessions and
monthly check up
weekly therapy sessions and monthly
check up

13. QUESTIONS
1. The nurse practitioner is educating Bonnie about the risk factors of stroke. Bonnie is best able to differentiate non-modifiable risk
factors from modifiable risk factors of stroke by stating: select all that apply.
a. Modifiable risk factors include, HTN, Carotid Disease, smoking, diabetes, hypocholesteremia, and hypercoagulability.
b. Non modifiable risk factors for stroke include are age, sex, sex, ethnicity
 All of the above.
 A and B.
2. Which statement made by Bonnie during a follow-up visit with her nurse practitioner will need further teaching by the provider?
 The imaging showed the plaques in my arteries are small therefore it is okay to missed couple of doses of the aspirin.
a. I understand ischemic stroke decreased the oxygen and glucose levels in my blood because of the blockage in my blood vessel.
b. I should limit exposure to reduced atmospheric pressure avoid carbon monoxide poisoning, and severe anemia as these
conditions can deprive oxygen in the blood flow.
c. None of the above.

14. REFERENCES
Augello, Noll, Distel, Wainright, Stout, & Ford. (2018). Identification of novel blood
biomarker panels to detect ischemic stroke in patients and their responsiveness to
therapeutic intervention. Brain Research, 1698, 161-169.
Boling, B., & Keinath, K. (2018). Acute Ischemic Stroke. AACN Advanced Critical
Care, 29(2), 152-162.
Hsieh, Lee, Wu, & Sung. (2018). Characteristics and outcomes of ischemic stroke in
patients with known atrial fibrillation or atrial fibrillation diagnosed after stroke.
International Journal of Cardiology, 261, 68-72.
Norris, T. L. (2019). Porths pathophysiology: Concepts of altered health states (10th
ed.). Philadelphia: Wolters Kluwer.
Red Eye. (n.d.). Retrieved from
https://my.clevelandclinic.org/health/symptoms/17690-red-eye
ScienceTech. (2019, January 23). Ischemic Stroke causes, symptoms, diagnosis,
treatment, pathology osmosis. Retrieved from
https://www.youtube.com/watch?v=nCUfZY71BcU