A 28-year-old female presented with neck pain, vomiting, and unconsciousness after being diagnosed with a posterior circulation stroke due to a dissecting aneurysm and antiphospholipid syndrome. She received extensive medical treatment, including intubation, mechanical ventilation, and rehabilitation, ultimately leading to her discharge on 17.04.2024 in stable condition. The case highlights the complexities of acute stroke management and the interdisciplinary approach required for recovery.

1. A CASE PRESENTATION ON
POSTERIOR CIRCULATION STROKE
STROKE ICU TEAM
CLINICAL NURSING SERVICES

2. INTRODUCTION
28 years old female brought to casualty with complaints
of
 Neck pain &Headache (2 days) 17.11.23
 Vomiting – 1episode(18.11.23) followed by
unconsciousness
 Weakness of left side limbs from 19.11.23

3. DEMOGRAPHIC DATA
 Full Name : Ms. Anjali Ravichandran
 Age : 28 years
 Gender : Female
 Education: Post Graduate
 Profession: Student Advisor / Counsellor
 Ward : Stroke Intensive Care Unit
 Date of admission in ICU : 23/11/2023
 Date of discharge: 17.04.2024

4. HISTORY OF PRESENT ILLNESS:
 The patient was apparently normal till 3/11/23, when
she developed fever which was moderate grade,
associated with chills and myalgia for which was
admitted in local hospital in Chennai for 3 days and was
detected to be dengue positive and was treated for the
same in IP care for 3 days.
 Patient was asymptomatic till 17/11/23 ,when she
developed neck pain, mild to moderate in severity
reduced on taking analgesics.

5. • On 18/11/23 patient developed sudden onset of severe
headache following which she had one episode of vomiting
followed by unconsciousness and was taken to a private
hospital, there they told she had hypotension and was
treated for the same. however patient remained in altered
sensorium.
HISTORY OF PRESENT ILLNESS:

6. • Next day on 19/11/23 patient developed weakness of
left upper and lower limbs, MRI done and was
diagnosed as midbrain and right hemi pontine infarct
• In view of low GCS score of 6/15, she was intubated on
20.11.2023 and kept on oxygen support via T piece
• Patient was then referred to NIMHANS on 23/11/23 for
further management
HISTORY OF PRESENT ILLNESS:

7. PAST HISTORY :
Past Medical – not a known case of T2DM ,HTN or
Hypothyroidism
Past Surgical – None
FAMILY HISTORY :
No of members : 4
Type : Nuclear
Family history of illness : Nil
Congenital Illness : Nil
HISTORY AND PHYSICAL EXAMINATION

8. HISTORY AND PHYSICAL EXAMINATION
PERSONAL HISTORY :
• Appetite – she consumed mixed diet
• Sleep – no prior sleep issues
• Narcotic addiction - None
• Alcohol addiction - None

9. HISTORY AND PHYSICAL EXAMINATION
SOCIOECONOMIC HISTORY
Monthly income : Rs. 50000/Month
housing : lives in Pucca house
PSYCHOLOGICAL STATUS
Ethnic background: Patient follows Hindu religion and culture
support system : Patient had good support system of family
and friends

10. PHYSICAL EXAMINATION
 GENERAL EXAMINATION :
 Blood pressure : 130/90 mmHg
 Temperature : 98.2 F
 Pulse rate : 90 beats/min
- regular rhythm, normal volume, all peripheral pulses
present equally on both sides
 Respiratory rate : 19 breaths/min

11. PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION :
On Observation
 Built : Endomorphic
 Nutrition : Mixed
 Pallor : Absent
 Icterus : Absent
 Oedema : Absent
 Cardiac : s1 s2 heard normal, no murmurs
 Abdomen : soft, no organomegaly

12. NERVOUS SYSTEM EXAMINATION:
 Higher Mental Function and Coordination Cannot be assessed
due to weakness and altered sensorium

13. NERVOUS SYSTEM EXAMINATION:
 GCS: E3VTM5
 Pupils B/L 2 mm equal and reactive to light
 EOM – Right eye abduction and adduction restriction
Left eye adduction restriction

14. NERVOUS SYSTEM EXAMINATION:
• No facial asymmetry present
• Motor Tone: Grade 2 spasticity
in left upper and lower limb
• Grade 1 spasticity in Right
upper and lower limb

• Plantar responses: Bilateral extensor
• Sensory system: withdraw limb to pain
• Cerebellar signs: Could not be
assessed.

15. INVESTIGATIONS
- STROKE WORK UP
 CT Brain and CT Angiography and MRI brain
 Cardiac evaluation ( ECG and 2 D echo)
 Chest X- ray and HRCT
 Blood investigations
 ANA profile, ANCA, ESR,CRP,RA factor,
 APLA
 PT/INR/APTT, CBC, LFT,RFT, Serum Electrolytes, Lipid
profile, vitamin B12, homocysteine ,
 Renal Doppler and bilateral lower limb Doppler

16. BLOOD INVESTIGATIONS
 CBC, LFT, RFT, SERUM ELECTROLYTES and TFT was normal
 Vitamin B12, FOLATE AND HOMOCYSTEINE was normal.
 Vasculitis work up including ANA, ANCA, ESR AND RA factor which was
negative.
 APLA Profile was sent, which showed anti-cardiolipin antibody and beta 2
glycoprotein antibody was positive.
TEST PATIENT VALUE NORMAL VALUE
ANTICARDIOLIPIN
ANTIBODY
78.60 MPLU/ML < 20:NEGATIVE
BETA 2
GLYCOPROTEIN (IgM)
149.60RU/ML <20RU/MLNEGATIVE

17. BLOOD SUPPLY TO THE BRAIN

18.  CT BRAIN PLAIN
 Shows infract in the right pons and vermis.

19.  MRI BRAIN
 Showed acute infract involving
pons (right half predominantly),
medulla and left cerebellar
hemisphere.
 MRI reveals absence of flow
related enhancement with
thrombus induced susceptibility of
basilar top and dissecting
aneurysm was noted at the left V3
VA just proximal to its intradural
course.

20. CT ANGIOGRAPHY
 Shows total occlusion of basilar top is seen for a distance
of approx. 1cm.

21.  ULTRASOUND VENOUS
DOPPLER
Did not shows evidence
of DVT.
 HRCT THORAX
Showed bilateral lower
lobe ground glass opacity
suggestive of aspiration
pneumonia and patient was
started on empirical antibiotics.

22. ECG

23. 2D ECHO
NORMAL STUDY

24. USG ABDOMEN
NORMAL STUDY

25. MEDICAL DIAGNOSIS
POSTERIOR CIRCULATION STROKE DISSECTING
ANEURYSM OF LEFT VERTEBRAL ARTERY V3 – V4
JUNCTION
ANTIPHOSPHOLIPID ANTIBODY SYNDROME

26. SIGNS AND SYMPTOMS
BOOK PICTURE PATIENT PICTURE
Vertigo COULD NOT ASSESS BECAUSE OF ALTERED
SENSORIUM
Ataxia
Motor deficits SPASTICITY GRADE 2 IN LEFT UL & LL
GRADE 1 IN RIGHTT UL & LL
Vomiting PRESENT
Headache PRESENT
CRANIAL NERVE
ABNORMALITIY 3rd CN and
6th CN
EOM- RT EYE ABDUCTION AND ADDUCTION RESTRICTION
LT EYE ADDUCTION RESTRICTION
ALTERED SENSORIUM GCS – E3VTM5

27. BOOK PICTURE PATIENT PICTURE
Dysphagia COULD NOT ASSESS BECAUSE OF
ALTERED SENSORIUM
Diplopia
Dysarthria
Dizziness
Dyspraxia

28. ETIOLOGY AND RISK FACTORS
Book picture Patient picture
Arterial atherosclerosis _
cardiac embolization _
Previous stroke or TIA _
Carotid artery disease _
Vascular obstruction or occlusion _
Auto immune and hyper-coagulable
disorders.
Antiphospholipid antibodies syndrome.
immune system mistakenly create
antibodies that attacks tissues in the
body. These antibodies can cause blood
clots to form in arteries and veins. APLA
Profile was sent, which showed anti-
cardiolipin antibody and beta 2
Glycoprotein antibody was positive
Aneurysms Dissecting aneurysm was noted at the
left V3 V4 of VA just proximal to its
intradural course.

29. PATHOPHYSIOLOGY
DISSECTING ANEURYSM IN THE V3 &V4
JUNCTION IN THE LEFT VERTEBRAL ARTERY
FORMATION OF THROMBUS
THROMBUS DISLOGED INTO THE
BASILAR ARTERY
DISRUPTION OF BLOOD FLOW IN
THE BASILAR AND CEREBELLAR
ARTEY
INFARCT IN THE PONS, VERMIS &
MEDULLA
POSTERIOR CIRCULATION STROKE

30. COURSE IN HOSPITAL
 The patient was received in stroke ICU on 23/11/23 and was kept on
mechanical ventilator support with spontaneous mode. GCS E3VTM5
 Patient was kept on T piece trial with Oxygen from 27.11.24
 Patient developed continuous fever, high spikes with rise in inflammatory
markers(CRP& Procal) and increased TC count 16,000 ,culture (4/12/23) was
sent which showed growth of streptococcus haemolyticus sensitive to
vancomycin and was started with Inj. Vancomycin 1 gm IV BD on 06.12.23
 Patient developed involuntary clonic movement of left hand and anti-seizure
Rx was initiated . Patient was tried to wean off from the ventilator, however
failed and hence surgical tracheostomy was done on 9/12/2023 and
continued with mechanical ventilation with spontaneous mode

31. COURSE IN HOSPITAL
 Since patient had continuous fever spikes, started with dual antibiotic inj.
Meropenem 1gm IV BD from 09.12.23
 She was started with weaning from 25/12/23 and tolerated off vent
 Patient also started obeying commands evidenced by eye movements but
motor deficit persists
 On 05/ 12/23 patient was shifted to EICU
 On 08/01/24 patient BP was dropped to 70/45 mmHg and started with
inotropic support (inj. Noradrenaline 4/40 at 5 ml / hr which was gradually
weaned and stopped on 10th and patient also maintained normal vital
signs

32. o The Tracheal culture report sent on 06/01/24 shows growth of
pseudomonas aeruginosa sensitive to Inj. colistin and was started with
Inj. colistin 4.5MIU IV BD from 09/01/24
o Patient was fully kept off vent from 13.01.24 and also afebrile and was
planned and shifted to step down ward on 15.01.24
o Patient showed gradual improvement in sensorium and was weaned
off ventilator.
o Trachestormy tube was gradually downsized from 7.5mm mm to 6 mm.
Plan was made to decannulate the tracheostomy tube, however patient
did not tolerate complete closure of tracheostomy tube.
COURSE IN HOSPITAL

33. COURSE IN HOSPITAL
o ENT opinion was sought for the same and advise to defer the
procedure and to give trial of oral feeds. Inputs were taken from
department of DPNR and PSW.
o Patient was continued on rehabilitation measures
o Nature and prognosis was explained to parents. Patient was
discharged in hemodynamically stable condition

34. COURSE IN HOSPITAL
Date of admission in stroke ICU : 23/11/2023
On ventilator from 23.11.23 to 11.01.24
Weaning from 01.01.24 to 11 .01.24
Fully off vent : 13.01.24
Transfer to EICU: 05/01/24
Transfer to Step down ward:15/01/24
Date of discharge: 17.04.24
Date of intubation:20.11.23(7.5mm)
D.O.T :09/12/23(7.5mm)
Downsizing :25.01.24(6.5 mm)
Downsizing :28.02.24(6mm)

35. TEAM DYNAMICS IN CARE OF THE PATIENT

36. MANAGEMENT
ACUTE STOKE CARE
 Airway management and ventilator support
 Blood pressure regulation
 Management of cerebral edema
 Managing and monitoring of elevated ICP
 Pharmacotherapy

37. PHARMACOLOGICAL MANAGEMENT
1. ANTIPLATELETS
i. Tab Ecospirin 75mg OD
ii.Tab Clopidogrel 75 mg OD
6.LIPID LOWERING AGENTS
i.Tab Atorvastatin 40 mg HS
2. ANTICOAGULANTS
i.Inj Heparin 5000IU s.c BD.
7.ANTIDEPRESSANTS
i.Tab Escitalopram 10 mg HS
2. ANTIEPILEPTIC
i.Tab Levetiracetam 1.5 gm BD
ii.Tab Clobazam 10 mg HS
8. ANTIBIOTICS
1. Inj Ceftriaperazone Salbactum (1.5gm) 1.V BD
2. Inj Meropenem 1 gm I.V BD
3. Inj Colistin 4.5 mIU I.V BD
4. Inj Vancomycin 1gm I.V BD
3. NEUROPROTECTIVE
AGENTS
i. Tab Strocit plus BD
4. ANTACIDS
i.Inj Pantaprazole 40mg I.V OD
5. SUPPLEMETS
i.Tab Homin OD.

38. NUTRITIONAL MANAGEMENT
 Nutritional assessment of patients and regular review of
nutritional status has been done.
 Nutritional plan has been done and 300ml 0f hospital
feeds were given every 3rd hourly by RT.
 Ruled out any malnutrition or protein deficiency.
 Assessed for diarrhea, constipation and modification of
diet has been done accordingly by dietician.
 Discharge advice including feeding techniques and
consistency of foods were thought.

41. PHYSIOTHERAPY
 Patient had poor bed mobility and poor transferring
skills, weakness in bilateral upper and lower limbs and
unable to stand.
 Patient was assessed for posture, balance, voluntary
movement, involuntary movement, tone, reflexes,
sensation and functional activities each time.
 Assed for immobility associated complications like DVT
and pulmonary embolism.
 ROM exercises has been given everyday.
 Patient had spasticity grade 2 in left UL & LL has been
advised to put split to leg and brace to shoulder.

42. PHYSIOTHERAPY
 Patient showed improved
sensory function
flexibility, joint integrity ,
motor control and
reduced spasticity while
discharge.
 Patient has been thought
about exercises and
regular physiotherapy to
be continued after
discharge.
 Currently patient is
walking with support and
has mild weakness in left
upper limb

44. SPEECH AND LANGUAGE
 Speech, comprehension,
and language deficits are
the most difficult problem
for the patient and family.
 Speech therapists
assessed and formulated
a plan to support
communication.
 Thought speech and
swallowing exercises

45. PSYCHOSOCIAL SUPPORT
 Initial screening and evaluation of
patients and families had done.
 Helped the patients and family
members to deal with the many
aspects of the patients condition-
social, financial, and emotional
problems.
 Social workers assisted individuals
and families in financial assistance
by referring hospital financial aid
services,
The patient was under APL scheme
And availed financial assistance of Rs.
40000 under ECGC from hospital.

46. OCCUPATIONAL THERAPY
 Occupational therapy is a
program that helps with
recovery after a stroke,
based on the client's
condition.
 Indepth assessment of the
areas of concern were done.
 Provided Adaptive techniques
and equipment to promote an
independent lifestyle.
 Thought the caregiver to
prevent the development of
any secondary complications
 Provided psychological
support to the client and
caregiver involving the client
in social gatherings and work.

47. NURSING MANAGEMENT

48. NURSING DIAGNOSES
- ACTUAL
 Ineffective cerebral tissue perfusion related to basilar artery
occlusion.
 Impaired breathing related to Acute infarcts involving the brain
stem
 Ineffective airway clearance related to acute infection of
bilateral lower lobe of lungs and poor cough reflex
 Impaired physical mobility related to weakness of upper and
lower limb secondary to basilar artery occlusion
 Self care deficit related to motor or sensory deficits

49. NURSING DIAGNOSES
- ACTUAL
 Hyperthermia related to acute infection of bilateral lower lobe of lungs
 Impaired verbal communication related to inability for articulation
secondary to intubation
 Impaired urinary elimination related to motor or sensory deficits
 Impaired bowel elimination related to motor or sensory deficits
 Disabled family coping related to catastrophic illness, cognitive and
behavioral squeale of stroke and care giving burden

50. NURSING DIAGNOSES
-POTENTIAL
 Risk for fall related to involuntary clonic movements
of upper limbs
 Risk for infection related to long term mechanical
ventilation and catheterization
 Risk for imbalanced nutrition related to impaired
oral intake
 Risk for impaired skin integrity related to prolonged
immobility

51. GOALS
 Goals are that the patient will
 Maintain stable or improved level of consciousness
 Maintain patent airway
 Attain maximum physical functioning
 Maximize self-care abilities and skills
 Maintain stable body functions
 Maximize communication abilities.
 Avoid complications of stroke.
 Maintain effective personal and family coping.

52. PROMOTE RESPIRATORY FUNCTION
MANAGEMENT OF THE
RESPIRATORY SYSTEM IS A
NURSING PRIORITY.
1.Assess the respiratory rate,
rhythm pattern and abnormal
breath sounds.
2. Monitor ABG value and
pulse oximetry
3.Closely monitor ventilator
parameters, alarms and
readiness for weaning.

53. 4. Secure ETT properly.
5. Assess for possible early complications( Rapid
electrolyte changes, Severe alkalosis, Hypotension
secondary to change in Cardiac output).
6. Suction as needed to maintain a patent airway.
7.Turn and reposition every 2 hours along with chest
physiotherapy.
8. Monitor for signs of respiratory distress: Restlessness,
Apprehension, Irritability and increase HR.
9. Administer medications as prescribed ( Mucolytics,
bronchodilators)
PROMOTE RESPIRATORY FUNCTION

54. NEUROLOGIC SYSTEM
1. Closely assess and monitor neurological status (pupils, GCS and
limb movements) frequently and compare with baseline.
2. Evaluate pupils, noting size, shape, equality, light reactivity.
3. Monitor vital signs: changes in blood pressure, compare BP readings
in both arms.
4. Position with head slightly elevated and in neutral position.
5. Maintain bed rest, provide quiet and relaxing environment, restrict
visitors and activities

55. 6. Assess for nuchal rigidity, twitching, increased restlessness, irritability,
onset of seizure activity
7. Administer medications as indicated:
Antiplatelet agents
Antihypertensives
Neuroprotective agents
 Antiepileptics
NEUROLOGIC SYSTEM

56. CARDIOVASCULAR SYSTEM
Goals aimed at maintaining homeostasis
1. Monitoring vital signs frequently
2. Monitoring cardiac rhythms
3. Calculating intake and output, noting imbalances
4. Regulating IV infusions
5. Adjusting fluid intake to the individual needs of the patient
6. Monitoring lung sounds for crackles and rhonchi (pulmonary
congestion)
7. Monitoring heart sounds for murmurs

57. MUSCULOSKELETAL SYSTEM
Goal is to maintain optimal function.
1. Assess extent of impairment initially and on a regular basis
2. Change positions at least every 2 hr (supine, side lying) and
possibly more often if placed on affected side.
3. Evaluate need for positional aids and/or splints during
spastic paralysis ( she was on B/L resting hand splints & B/L
resting AFO)
4. Place pillow under axilla to abduct arm
5. Place finger exercise ball in the palm with fingers and thumb
opposed.

58. MUSCULOSKELETAL SYSTEM
6. Maintain leg in neutral position
7. Observe affected side for color,
edema, or other signs of
compromised circulation.
 8. Begin active or passive ROM to
all extremities (including splinted) from
admission.
 9. Assist patient with exercise and
perform ROM exercises for both the
affected and unaffected sides.

59. INTEGUMENTARY SYSTEM
 Susceptible to breakdown related to
 Loss of sensation
 Decreased circulation
 Immobility
 Compounded by patient age, poor nutrition, dehydration,
edema, and incontinence

60. PREVENTION OF BED SORE
1. Assess pressure points for signs of bed sore development
2. Provide pressure-redistribution surface.
3. Following each incontinent episode, clean area and dry thoroughly.
4. Protect skin with moisture-barrier ointment
5. Establish individualized turning schedule.
6. Change position at least once in two hours and more frequently for
the high risk individuals.
7. Provide adequate nutritional and fluid intake
8. Use comfort devices appropriately.

62.  GASTROINTESTINAL SYSTEM
 Prevention of stress ulcer/ G.I. bleeding
 Prevention of Constipation.
-Patients may be placed on stool
softeners.
 Physical activity for promoting bowel
function.
 Maintaining adequate nutrition

63. URINARY SYSTEM

64. SENSORY SYSTEM
1. Observe behavioural responses: crying, inappropriate affect.
2. Establish and maintain communication with the patient. Set up a
simple method of communicating basic needs. Repeat yourself
quietly and calmly and use gestures when necessary to help in
understanding.
3. Eliminate extraneous noise and stimuli as necessary.
4. Speak in calm, comforting, quiet voice, using short sentences.
Maintain eye contact.
5. Stimulate sense of touch. Give patient objects to touch, and
hold.

65. COPING
1. Determine outside stressors: family, work, future healthcare needs.
2. Provide psychological support and set realistic short-term goals.
Involve the patient’s caregiver in plan of care when possible and
explain her deficits and strengths.
3. Emphasize small gains either in recovery of function or independence.
4. Support behaviors and efforts such as increased interest/participation
in rehabilitation activities.
5. Monitor for sleep disturbance, increased difficulty concentrating,
statements of inability to cope, lethargy, withdrawal.
6. Refer for neuropsychological evaluation and/or counselling if
indicated.

66. PREVENTION OF COMPLICATIONS

67. PREVENTION OF DVT
1. Deep vein thrombosis can be prevented, especially if
patients who are considered high risk are identified and
preventive measures are instituted without delay.
2. Graduated compression stockings. Compression stockings
prevent dislodgement of the thrombus.
3. Pneumatic compression device. Intermittent pneumatic
compression devices increase blood velocity beyond that
produced by the stockings.
4. Leg exercises. Encourage early mobilization and leg
exercises to keep the blood circulating adequately
5. Pharmacological prophylaxis using anticoagulants

69. PREVENTION OF INFECTION
Prevention of all HAIs by following aseptic techniques and strict
hand hygiene

70. AMBULATORY AND HOME CARE
 Discharge planning with the patient
and family starts early in the
hospitalization and promotes a
smooth transition from one care
setting to another.
 Evaluation of self-care skills
 Prepare the patient and family for
discharge through
 Education
 Demonstration
 Practice
 Rehabilitation to promote optimal
functioning.
 Physical, mental, and social well-being