Stroke is the 2nd leading death associated disorder. It is also known as cerebrovascular disorder mainly caused by high blood cholesterol levels or rupture of cerebral arteries.

1. CASE ON Lt ACUTE MCA
TERRITORY INFARCT AND
WATER VESSEL INFARCT
By,
Umme Habeeba A Pathan
4th Pharm D
Roll no : 29
Bapuji Pharmacy college
Davangere

3. TYPES OF STROKE

4. SUBJECTIVE
• NAME : XYZ
• AGE : 68 years
• GENDER : MALE
• IP NO : IP1911170081
• WARD : MICU
• DOA : 17/11/2019
• DOD : 24/11/2019

5. • Reason for admission :
1. c/o weakness of right upper limb and right
lower limb since 2 days,
2. not responding to verbal commands,
3. deviation of angle of mouth to left side.
4. Aphasia since 3 days
5. Patient admitted had hyperglycemia and
hyponatermia likely due to hypovolemia
• PATIENT MEDICAL HISTORY:
1. K/C/O TYPE2 DM AND HTN SINCE 3 YEARS
• PATIENT MEDICATION HISTORY : Not
mentioned.

6. OBJECTIVE
O/E
• BP : 140/90 mm Hg
• PR : 82 bpm
• RR : 20 cpm
• CNS : Altered
consciousness
• Sensorium : Drowsy
• Spontaneous eye
movement : +ve
• Icterus : +ve
• Movement of right
upper limb : +ve
• Facial plasy : +ve
• Aphasia : +ve
• Pain score : 2
• ECG : sinus rhythm

7. LABORATORY INVESTIGATION(18/11/2019)
PARAMETERS OBSERVED VALUE NORMAL RANGE
Hb 15.0 mg/dl 13-18 mg/dl
RBC 5.2 million cells/mm³ 4.5-6.5 million cells/mm³
T.C 19300 cells/mm³ 4000-11000 cells/mm³
ESR 34 mm/hr 0-20mm/hr
Sr. Na 126.8 mmol/L 135-145mmol/L
Sr. K 3.8 mmol/L 3.5-5.0 mmol/L
Sr. Cl 92.5 mmol/L 100-105mmol/L
RBS 354 mg/dl <200mg/dl
Total bilirubin 1.3 mg/dl 0.3-1.2 mg/dl
Direct bilirubin 0.5 mg/dl Upto 0.2 mg/dl
Indirect bilirubin 0.8 mg/dl 0-0.6 mg/dl
A/G ratio 1.56 1.0-1.5
Urea 72.4 mg/dl 10-50 mg/dl
Sr. Cr 1.33mg/dl 0.7-1.2mg/dl

8. (18/11/2019)
PARAMETERS OBSERVED VALUE NORMAL RANGE
HbA1C 8.3% Upto 6%
Mean blood glucose 191.51mg/dl 100-130 mg/dl
Total cholesterol 212.1mg/dl ≤200mg/dl
Tri G 126.6 mg/dl 35.3-79.5 mg/dl
LDL 135.7mg/dl <100 mg/dl
VLDL 25.3 mg/dl 10-35 mg/dl
CT scan of brain : Scan shows MCA infarct
CCA(common carotid artery) thrombus < 56%

9. • (19/11/2019)
ECHOCARDIOGRAPY REPORT
1. VALVES:
a) Aortic valve : Sclerotic.
2. DOPPLER DATA:
a) Mitral : MR – Mild
b) Aortic : peak gradient - 10 mm Hg
c) Tricuspid : TR Trivial PASP- 28 mm Hg
d) Pulmonary : peak gradient- 3mm Hg
e) LVOT : normal
f) Vegetation/Thrombus : normal
g) Pericardium : normal

10. DIAGNOSIS
• BASED ON SUBJECTIVE AND OBJECTIVE
EVIDENCES PATIENT IS DIAGNOSED WITH
1. LEFT ACUTE MCA TERRITORY INFARCT WITH
WATER VESSEL INFARCT.
2. MILD MR WITH SCLEROTIC AORTIC VALVE.
FINAL DIAGNOSIS : ISCHEMIC STROKE

11. GOALS OF THERAPY
• To relieve signs and symptoms.
• To improve quality of life of patient.
• To stabilize the patient.
• The immediate goal is to re-establish adequate
blood flow in his diseased cerebral vessels.
• Longer-range objectives are to prevent
reocclusion, decrease the risk of future
symptomatic TIAs, and ultimately, prevent a
cerebral infarction.
• To restore the lost facial muscle and limb function
by physiotherapy.

12. PLAN (18/11/2019)
Sl no DRUG GENERIC NAME DOSE FREQUENCY
1 Inj Ondem Ondansetron 4mg 1-0-1
2 Inj Mannitol Mannitol 100mg 1-1-1-1
4 Inj Edavit Edaravone 1 amp in 100ml NS over
30 min
1-0-1
5 Inj cerehenz Cerebroprotien
hydrosylate
1amp in 100ml NS over
30 min
1-0-1
6 Syp oral glycerol Glycerol 30ml 1-1-1
7 Tab Ecosprin Aspirin 75 mg 0-0-1
8 Tab Clopidogrel Clopidogrel 75 mg 0-0-1
9 Tab Avas 80 atorvastatin 80 mg 0-0-1
IV LINE 1 IVF NS – 100 ml Every 1 hour 7am – 10 am (18/11/19)
IV LINE 2 3% NaCl – 10 ml Every 1 hour 9am – 6 am ( 19/11/19)
IV LINE 3 IV DNS – 50 ml Every 1 hour 9am – 6 am ( 19/11/19)

13. • Hepatitis B – Non Reactive
• HIV Rapid – Non Reactive
• T3 – 0.67ng/dl ( 0.4 - 1.8 ng/dl)
• T4 – 8.79 mcg/dl (5.0 – 10.7 mcg/dl)
• TSH – 2.11 IU/ml (0.5 – 8.9 IU/ml)
• Catheter associated UTI : checked
• Advise echocardiography and dietician
department review.
10 Inj Piptaz Piperacillin +
Tazobactum
4.5 g 1-0-1
11 Inj Xone Ceftriaxone 1g 1-0-1

14. DAY 2 (19/11/19)
O/E
• Conscious, obeying commands, vitals stable
• BP : 140/90 mm Hg
• Na⁺ : 131.2 mmol/L
• K⁺ : 3.8 mmol/L
• Cl⁻ : 96.7 mmol/L
• Consider increase calorie intake, RT feed every 4 hour
(700 calorie).
• Plan to decrease or stop fluid by evening (2L/day).
• Echocardiography report show sclerotic aortic valve
and mild MR.
• Catheter associated UTI : checked

15. IV LINE 1 IVF NS – 75 ml
30ml
Every 1 hour 7am – 10 am
11 am – 6 am
IV LINE 2 3% NaCl – 10 ml Every 1 hour 9am – 6 am
IV LINE 3 IV DNS – 40 ml Every 1 hour 11am – 6 am
Urea : 50.4 mg/dl
GRBS : 140 mg/dl
Rx
CST
Stop
Inj Xone

16. DAY 3 ( 20/11/19)
IV LINE 1 IVF NS – 75 ml
50ml
Every 1 hour 7am – 11 am
12 pm – 10pm
IV LINE 2 3% NaCl – 10 ml Every 1 hour 7am – 10 pm
IV LINE 3 IV DNS + Actrapid +
10 mg KCl @ 40
ml/hr
Every 1 hour 7am – 11 am (stopped)
O/E
BP : 150/90 mm Hg
Aphasia +ve
Facial palsy +ve
Na⁺ : 136.4 mmol/L
K⁺ : 3.3 mmol/L
Cl⁻ : 105.7 mmol/L
Rx
CST
adjust mannitol 1-1-1
Patient advised to shift to male
ward tomorrow
Case seen by endocrinology and reviewed , clinically
improved and no fresh complaints

17. DAY 4 ( 21/11/19)
• Patient shifted to male general ward.
• O/E; BP : 140/80 mm Hg
• Advise Physiotherapy
• RT feed 100ml every 4 hourly.
• Continue same therapy
• IVF NS @ 75ml/hr till 10pm and stop it.
• IVF 3% NaCl @ 10ml/hr till 10pm and stop it.

18. DAY 5 ( 22/11/19)
• O/E
• BP : 130/90 mm Hg
• CNS : conscious and oriented.
• RT feed 3rd hourly 100ml
• IVF can be stopped.
• Inj Actrapid 6 – 6 – 6 – 5
• Inj Lantus 7 – 0 – 0 – 6
• Physiotherapy continued and CST.
(15 min before food) 7am-11am-5pm-10pm
9am 10pm

19. DAY 6 ( 23/11/19)
O/E BP : 130/90 mm Hg
PARAMETERS OBSERVED VALUE NORMAL RANGE
Hb 14.8 mg/dl 13-18 mg/dl
RBC 5.1 million cells/mm³ 4.5-6.5 million cells/mm³
T.C 13100 cells/mm³ 4000-11000 cells/mm³
PCV 44.4% 47± 7%
RDW 13.3 11-15
Platelet Count 3.03 lakh cells 1.5 – 4.5 lakh cells
CNS : conscious and oriented
Obey commands
GRBS monitoring : 7am 11 am 5 pm 9pm
Inj actrapid 5 – 4 – 4 – 4
Inj lantus 6 – 0 – 0 – 5
Rx
CST
Physiotherapy continued….
Patient is advised on discharge

20. • Day 7 ( 24/11/19)
• BP : 130/90 mm Hg
PARAMETERS OBSERVED VALUE NORMAL VALUE
TC 11000 cells/mm³ 4000-11000 cells/mm³
FBS 130 mg/dl <100 mg/dl
RBS 195 mg/dl <200 mg/dl
Total cholesterol 200mg/dl ≤200mg/dl
Urea 45mg/dl 20-50 mg/dl
Total cholesterol 190.1mg/dl ≤200mg/dl
Tri G 96.6 mg/dl 35.3-79.5 mg/dl
LDL 95.7mg/dl <100 mg/dl

21. DISCHARGE MEDICATION
SL
NO
DRUG GENERIC NAME DOSE FREQUENCY NO OF DAYS
1 Tab Ecosprin Aspirin 75 mg 0-0-1 10
2 Tab Clopidogrel Clopidogrel 75 mg 0-0-1 10
3 Tab Colihenz Citocoline+
Piracetam
500mg+
400 mg
1-0-0 30
4 Tab Avas 80 Atorvastatin 80 mg 0-0-1 10
5 Inj. H. mixtard Inj insulin 20-0-10 1-0-1 15
REVIEW AFTER 10 DAYS

22. GOALS ACHIEVED
• Patient’s life became better.
• Patient’s CNS became conscious and oriented.
• Patient started to obey commands.

23. MONITORING PARAMETERS
• Disease monitoring :
1. Risk of bleeding (hemorrhage), infection, blood pressure, radial artery
pulse monitoring.
2. Stroke survivors are at increased risk of recurrent ischemic events,
including recurrent stroke and myocardial infarction (MI). Particularly in
the first hours and days after a transient ischemic attack (TIA) or stroke,
risk of recurrence is high. Recurrent strokes lead to dementia more often
and have higher case fatality than first strokes
• Drug monitoring :
1. Aspirin, Clopidogrel – antiplatelet have high risk of bleeding.
2. Ondem – monitor electrolytes
3. Mannitol – discontinue if renal, cardiac or pulmonary status worsens or
CNS toxicity develops.
4. Cerebroprotien hydrolysate – monitor protein levels
5. Edaravone – monitor hypersensitive reaction.
6. Glycerol -
7. Regular insulin and insulin glargine : monitor blood glucose level.

24. PHARMACIST ACTIVITY
• Drug interaction:
Moderate drug interactions were found –
1. Aspirin <> Clopidogrel – unusual bleeding may occur.
Carefully monitor the risk of bleeding.
2. Atorvastatin <> Clopidogrel – combination reduces
the efficacy of clopidogrel . Dosage adjustment is
necessary.
3. Aspirin <> insulin glargine
4. Aspirin <> insulin regular
These both interaction can cause risk of hypoglycemia
but patient is monitored with RT feed.

25. • INTERVENTIONS:
Inj ondem is given without indication. It may
lead to serotonin syndrome.
No hepatoprotectancts were given for
abnormal LFT. Drug like silymarin 560 mg OD
can be given.
No anti seizures were prescribed when patients
eye movement was positive. Drug of choice for
post stroke seizures is Lorazepam 4mg OD.

26. PATIENT COUNSELLING
• ABOUT DISEASE :
1. Call 108 in emergency situation.
2. Take your medicine as directed.
3. Go to stroke rehabilitation(rehab) if directed.
4. Wear pressure stockings as directed.
5. Control your blood sugar level if you have
hyperglycemia or diabetes.
6. Mirror therapy at rehabilitation.
• ABOUT DRUGS :
1. The drugs patient is taking has high risk of bleeding so avoid
cuts and wounds.
2. Instruct patient about the use of insulin pen.

27. • Life style modification.
1. Exercise as directed not more or less.
2. Make your home safe. Remove anything you might
trip over.
3. Eat a variety of healthy foods. Healthy foods include
whole-grain breads, low-fat dairy products, beans,
lean meats, and fish. Eat at least 5 servings of fruits
and vegetables each day. Choose foods that are low in
fat, cholesterol, salt, and sugar. Eat foods that are high
in potassium, such as potatoes and bananas. A
dietitian can help you create healthy meal plan.
4. Maintain a healthy weight. Ask your healthcare
provider how much you should weigh. Ask him or her
to help you create a weight loss plan if you are
overweight. He or she can help you create small goals
if you have a lot of weight to lose