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Cerebral Occlusion

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Cerebral Occlusion

Student’s Name

Institutional Affiliation

Summary of the Patient

While on duty, 37 years old man was admitted to the health facility showing various symptoms. After a few minutes of the say, he experienced the immediate onset of progressive dysarthria, facial paresis, ataxia as well as horizontal gaze palsy. Equally, the patient conditions worsened within the next few minutes showing left hemiparesis. We conducted computerized tomography one hour after the onset of the symptoms after the National Institutes of Health Stroke Scale Score indicated 13. Moreover, results revealed the absence of intracranial bleeding or brain stem lesions. However, upon carrying out the computed tomographic angiography, the results showed the middle basilar vessel occlusion. The results suggested the embolic basilar artery occlusion with further 5F diagnostic and a 4-vessel angiogram confirming basilar artery occlusion. The treatment procedures started with the insertion of the 6F guiding catheter in the right vertebral artery.  Furthermore, I placed the 27 microcatheters, 0.021-inch size Rebar, as well as 0.14-inch Silverspeed, loaded with coaxially into the thrombus (Alemseged et al., 2017). Similarly, administration of the tissues plasminogen followed at a rate of 40mg/30 min intra-arterially. The navigation of the Rebar 27 microcatheter occurred past thrombus hence entering the P1 segment on the left side (Papanagiotou et al., 2010).   The next step involved placing and deploying the stent from the left P1 segment into the basilar artery while the middle third of the device remained in the thrombus formation. Moreover, the device followed the course of the vessel gently without displacement.  The procedure showed complete recanalization of the basilar artery occlusion, and finally, the thrombus material was found located within the stent.

Issues Discussed with Preceptor

After encountering the patients with such conditions, I discussed various issues with the preceptor. Firstly, I discussed with the instructor on symptoms of the patient and possible disorder he was suffering from since we had training on such conditions before. The first issues after patient admission were on how to handle the patient in terms of the position of head and body on the tables to enhance blood floor to head as well as balancing the blood pressures. Such issues significantly existed as the first aid before performing the first diagnostic test. Furthermore, conducting computerized tomography or computed tomographic angiography existed as the point of focus based on the symptoms shows by the patient. The two tests would significantly show the presence of brain hemorrhage, but computerized tomography would lack the positive results for basilar artery occlusion.

OLDCART Note

Onset = 48 hour ago

Location:  mostly in the head

Duration:  from the onset time. Sweating at night, mostly on my head.

Characteristics:  progressive dysarthria, facial paresis, ataxia as well as horizontal gaze palsy

and left hemiparesis.

Aggravating factors: The condition gets worse at night and during the day. I sweat too much during the night during the day I feel a lot of headaches. Furthermore, when I get involved too much in some physical activities like working, talking, or standing for long, the condition worsens.

Relieving factors: the symptoms lower down and feel relieved when I sit down and relax in well-ventilated areas.

Treatment: I have been using headache drugs like aspirin and ibuprofen.

AHRQ National Guidelines 

Agency for Healthcare Research and Quality (AHRQ) offers various national guidelines for the management of the basilar artery occlusion aiming at saving the lives of the p[patients in such conditions.  Firstly, training of the healthcare provider on the basilar artery occlusion marks the first step in guidelines (Agency for Healthcare Research and Quality, 2016). The training helps the clinicians to recognize and diagnose the symptoms of the disorder at the moment the patients get admitted. Furthermore, the training equips the care providers with skills and knowledge on the first step to conduct while dealing with patients of such conditions (Agency for Healthcare Research and Quality, 2016). Secondly, the guidelines explain that if suspecting the patients suffer from basilar artery occlusion, then the clinician should first consider augmenting the blood pressure of the patient by putting his or her head on a flat bed, which increases cerebral perfusion at the time of admission. Thirdly, the healthcare provider should carry out non-contrast CT angiography and as well as head CT and the foremost diagnostic testing.  In case the result shows no signs of brain hemorrhage and the symptoms persist within four hours, then clinicians should administer the V tissue-type plasminogen activator (t-PA) as the preferred and standard care (Agency for Healthcare Research and Quality, 2016).  On the same note, after the patient stabilization procedures, the care providers and professionals should direct the work up to examine the basilar artery occlusion etiology. As per the Agency for Healthcare Research and Quality (2016), the process of obtaining the MRI brain to evaluate the edema and lesion burden should follow. Similarly, the care providers should conduct the CTA on both neck and head examines the occlusion, dissection, and luminal narrowing of the patient. Notably, as the guidelines state, the patient should receive regular cardiac monitoring to investigate atrial fibrillation, which could offer the results in preventing the secondary basilar artery occlusion as well as providing management directions.  Finally, patients should receive close monitoring of the blood pressure as these individuals possess high senility to the changes in blood pressure (Demel & Broderick, 2015). The monitoring should include cerebellar edema that could result in compression of the fourth ventricle and herniation, which could happen three to five days after the infarction.

Current Research on Basilar Artery Occlusion

Basilar Artery International Cooperation Study (BASICS) currently conducts different trials in determining the safety and effectiveness of additional intra-arterial medication after the intravenous treatment in patients suffering from basilar artery occlusion. As per Alemseged et al. (2017), such extra medication includes the administration of drugs aimed at controlling the blood pressure of the patients after treatments due to high sensitivity to the change in blood pressure. Furthermore, current research on the basilar artery occlusion concentrates on predict clinical outcomes of the disease. Posterior Circulation Collateral Score (PC-CS) exists as one of the predicts under the study (Alemseged et al., 2017). The posterior circulation originating from the anterior one happens through the posterior communicating artery (PCOM). As a result, the research work shows that employing the catheter cerebral angiography confirms the excellent results in patients suffering from a collateral filling type of basilar artery occlusion (Demel & Broderick, 2015). The procedure involves the digital subtraction angiography to the patients, which offer different types of occlusions.

The recent studies on basilar artery occlusion significantly influence my profession as a clinician. Clinical decision making forms a fundamental part of excellent healthcare personnel. While handling the patients with cases of basilar artery occlusion, deciding on the medical procedures requires various references of the patient’s symptoms to the past and existing material as well as ongoing research works. Personally, the studies would provide an effective and on-time diagnosis as well as treatment procedures of the disease, which would influence the medical decisions before conducting the first test or administering the first treatment. The research work, if successfully implemented into the healthcare industry, would help in accurate and quick decision making on acute disorders like basilar artery occlusion, which would help in saving lives.

 

References

Demel, S. L., & Broderick, J. P. (2015). Basilar occlusion syndromes: an update. The Neurohospitalist5(3), 142-150.

Papanagiotou, P., Roth, C., Walter, S., Behnke, S., Politi, M., Fassbender, K., … & Reith, W. (2010). Treatment of acute cerebral artery occlusion with a fully recoverable intracranial stent: a new technique. Circulation121(23), 2605-2606.

Agency for Healthcare Research and Quality. (2016). Tools | Agency for Health Research and Quality. Retrieved 30 January 2020, from https://www.ahrq.gov/tools/index.html?search_api_views_fulltext=&field_toolkit_topics=14168&sort_by=title&sort_order=ASC&search_api_fulltext=&sorting=title%7CASC&page=2

Alemseged, F., Shah, D. G., Diomedi, M., Sallustio, F., Bivard, A., Sharma, G., … & Parsons, M. W. (2017). Abstract WMP20: The Basilar Artery on Computed Tomography Angiography (batman) Prognostic Score for Basilar Artery Occlusion. Stroke48(suppl_1), AWMP20-AWMP20.

 

 

 

 

 

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