nursing case study for stroke patient

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This case study presents a 68-year old “right-handed” African-American man named Randall Swanson. He has a history of hypertension, hyperlipidemia and a history of smoking one pack per day for the last 20 years. He is prescribed Atenolol for his HTN, and Simvastatin for Hyperlipidemia (but he has a history of not always taking his meds). His father had a history of hypertension and passed away from cancer 10 years ago. His mother has a history of diabetes and is still alive.

Randall was gardening with his wife on a relaxing Sunday afternoon. Out of nowhere, Randall fell to the ground. When his wife rushed to his side and asked how he was doing, he answered with garbled and incoherent speech. It was then that his wife noticed his face was drooping on the right side. His wife immediately called 911 and paramedics arrived within 6 minutes. Upon initial assessment, the paramedics reported that Randall appeared to be experiencing a stroke as he presented with right-sided facial droop and weakness and numbness on the right side of his body. Fortunately, Randall lived nearby a stroke center so he was transported to St. John’s Regional Medical Center within 17 minutes of paramedics arriving to his home.

Initial Managment

Upon arrival to the Emergency Department, the healthcare team was ready to work together to diagnose Randall. He was placed in bed with the HOB elevated to 30 degrees to decrease intracranial pressure and reduce any risks for aspiration. Randall’s wife remained at his side and provided the care team with his brief medical history which as previously mentioned, consists of hypertension, hyperlipidemia and smoking one pack per day for the last 20 years. He had no recent head trauma, never had a stroke, no prior surgeries, and no use of anticoagulation medications.

Physical Assessment

Upon first impression, Nurse Laura recognized that Randall was calm but looked apprehensive. When asked to state his name and date of birth, his speech sounded garbled at times and was very slow, but he could still be understood. He could not recall the month he was born in but he was alert and oriented to person, time, and situation. When asked to state where he was, he could not recall the word hospital. He simply pointed around the room while repeating “here.”

Further assessment revealed that his pupils were equal and reactive to light and that he presented with right-sided facial paralysis. Randall was able to follow commands but when asked to move his extremities, he could not lift his right arm and leg. He also reported that he could not feel the nurse touch his right arm and leg. Nurse Laura gathered the initial vital signs as follows: BP: 176/82, HR: 93, RR: 20, T:99.4, O2: 92% RA and a headache with pain of 3/10.

Doctor’s Orders

The doctor orders were quickly noted and included:

-2L O2 (to keep O2 >93%)

– 500 mL Bolus NS

– VS Q2h for the first 8 hrs.

-Draw labs for: CBC, INR, PT/INR, PTT, and Troponin

-Get an EKG

-Chest X ray

-Glucose check

-Obtain patient weight

-Perform a National Institute of Health Stroke Scale (also known as NIHSS) Q12h for the first 24 hours, then Q24h until he is discharged

-Notify pharmacy of potential t-PA preparation.

Nursing Actions

Nurse Laura started an 18 gauge IV in Randall’s left AC and started him on a bolus of 500 mL of NS. A blood sample was collected and quickly sent to the lab. Nurse Laura called the Emergency Department Tech to obtain a 12 lead EKG.

Pertinent Lab Results for Randall

The physician and the nurse review the labs:

WBC 7.3 x 10^9/L

RBC 4.6 x 10^12/L

Plt 200 x 10^9/L

LDL 179 mg/dL

HDL 43 mg/dL

Troponin <0.01 ng/mL

EKG and Chest X Ray Results

The EKG results and monitor revealed Randall was in normal sinus rhythm; CXR was negative for pulmonary or cardiac pathology

CT Scan and NIHSS Results 

The NIH Stroke Scale was completed and demonstrated that Randall had significant neurological deficits with a score of 13. Within 20 minutes of arrival to the hospital, Randall had a CT-scan completed. Within 40 minutes of arrival to the hospital, the radiologist notified the ED physician that the CT-scan was negative for any active bleeding, ruling our hemorrhagic stroke.

The doctors consulted and diagnosed Randall with a thrombotic ischemic stroke and determined that that plan would include administering t-PA. Since Randall’s CT scan was negative for a bleed and since he met all of the inclusion criteria he was a candidate for t-PA. ( Some of the inclusion criteria includes that the last time the patient is seen normal must be within 3 hours, the CT scan has to be negative for bleeding, the patient must be 18 years or older, the doctor must make the diagnosis of an acute ischemic stroke, and the patient must continue to present with neurological deficits.)

Since the neurologist has recommended IV t-PA, the physicians went into Randall’s room and discussed what they found with him and his wife. Nurse Laura answered and addressed any remaining concerns or questions.

Administration

Randall and his wife decided to proceed with t-PA therapy as ordered, therefore Nurse Laura initiated the hospital’s t-PA protocol. A bolus of 6.73 mg of tPA was administered for 1 minute followed by an infusion of 60.59 mg over the course of 1 hour. ( This was determined by his weight of 74.8 kg).  After the infusion was complete, Randall was transferred to the ICU for close observation. Upon reassessment of the patient, Randall still appeared to be displaying neurological deficits and his right-sided paralysis had not improved. His vital signs were assessed and noted as follows: BP: 149/79 HR: 90 RR: 18 T:98.9 O2: 97% 2L NC Pain: 2/10.

Randall’s wife was crying and he appeared very scared, so Nurse John tried to provide as much emotional support to them as possible. Nurse John paid close attention to Randall’s blood pressure since he could be at risk for hemorrhaging due to the medication. Randall was also continually assessed for any changes in neurological status and allergic reactions to the t-PA. Nurse John made sure that Stroke Core Measures were followed in order to enhance Randall’s outcome.

In the ICU, Randall’s neurological status improved greatly. Nurse Jan noted that while he still garbled speech and right-sided facial droop, he was now able to recall information such as his birthday and he could identify objects when asked. Randall was able to move his right arm and leg off the bed but he reported that he was still experiencing decreased sensation, right-sided weakness and he demonstrated drift in both extremities.

The nurse monitored Randall’s blood pressure and noted that it was higher than normal at 151/83. She realized this was an expected finding for a patient during a stroke but systolic pressure should be maintained at less than 185 to lower the risk of hemorrhage. His vitals remained stable and his NIHSS score decreased to an 8. Labs were drawn and were WNL with the exception of his LDL and HDL levels. His vital signs were noted as follows: BP 151/80 HR 92 RR 18 T 98.8 O2 97% RA Pain 0/10

The Doctor ordered Physical, Speech, and Occupational therapy, as well as a swallow test.

Swallowing Screen

Randall remained NPO since his arrival due to the risks associated with swallowing after a stroke. Nurse Jan performed a swallow test by giving Randall 3 ounces of water. On the first sip, Randall coughed and subsequently did not pass. Nurse Jan kept him NPO until the speech pathologist arrived to further evaluate Randall. Ultimately, the speech  pathologist determined that with due caution, Randall could be put on a dysphagia diet that featured thickened liquids

Physical Therapy & Occupational Therapy

A physical therapist worked with Randall and helped him to carry out passive range of motion exercises. An occupational therapist also worked with Randall to evaluate how well he could perform tasks such as writing, getting dressed and bathing. It was important for these therapy measures to begin as soon as possible to increase the functional outcomes for Randall. Rehabilitation is an ongoing process that begins in the acute setting.

Day 3- third person 

During Day 3, Randall’s last day in the ICU, Nurse Jessica performed his assessment. His vital signs remained stable and WNL as follows: BP: 135/79 HR: 90 RR: 18 T: 98.9 O2: 97% on RA, and Pain 0/10. His NIHSS dramatically decreased to a 2. Randall began showing signs of improved neurological status; he was able to follow commands appropriately and was alert and oriented x 4. The strength  in his right arm and leg markedly improved. he was able to lift both his right arm and leg well and while he still reported feeling a little weakness and sensory loss, the drift in both extremities was absent.

Rehabilitation Therapies

Physical, speech, and occupational therapists continued to work with Randall. He was able to call for assistance and ambulate with a walker to the bathroom and back. He was able to clean his face with a washcloth, dress with minimal assistance, brush his teeth, and more. Randall continued to talk with slurred speech but he was able to enunciate with effort.

On day 4, Randall was transferred to the med-surg floor to continue progression. He continued to work with physical and occupational therapy and was able to perform most of his ADLs with little assistance. Randall could also ambulate 20 feet down the hall with the use of a walker.

Long-Term Rehabilitation and Ongoing Care

On day 5, Randall was discharged to a rehabilitation facility and continued to display daily improvement. The dysphagia that he previously was experiencing resolved and he was discharged home 1.5 weeks later. Luckily for Randall, his wife was there to witness his last known well time and she was able to notify first responders. They arrived quickly and he was able to receive t-PA in a timely manner. With the help of the interdisciplinary team consisting of nurses, therapists, doctors, and other personnel, Randall was put on the path to not only recover from the stroke but also to quickly regain function and quality of life very near to pre-stroke levels. It is now important that Randall continues to follow up with his primary doctor and his neurologist and that he adheres to his medication and physical therapy regimen.

Case Management

During Randall’s stay, Mary the case manager played a crucial role in Randall’s path to recovery. She determined that primary areas of concern included his history of medical noncompliance and unhealthy lifestyle. The case manager consulted with Dietary and requested that they provide Randall with education on a healthy diet regimen. She also provided him with smoking cessation information. Since Randall has been noncompliant with his medications, Mary determined that social services should consult with him to figure out what the reasons were behind his noncompliance. Social Services reported back to Mary that Randall stated that he didn’t really understand why he needed to take the medication. It was apparent that he had not been properly educated. Mary also needed to work with Randall’s insurance to ensure that he could go to the rehab facility as she knew this would greatly impact his ultimate outcome. Lastly, throughout his stay, the case manager provided Randall and his wife with resources on stroke educational materials. With the collaboration of nurses, education on the benefits of smoking cessation, medication adherence, lifestyle modifications, and stroke recognition was reiterated to the couple. After discharge, the case manager also checked up with Randall to make sure that he complied with his follow up appointments with the neurologist and physical and speech therapists,

• What risk factors contributed to Randall’s stroke?
• What types of contraindications could have prevented Randall from receiving t-PA?
• What factors attributed to Randall’s overall favorable outcome?

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Stroke Case Study (45 min)

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Mrs. Blossom is a 57-year-old female who presented to the Emergency Room with new onset Atrial Fibrillation with Rapid Ventricular Response (RVR). She is admitted to the cardiac telemetry unit after being converted to normal sinus rhythm with a calcium channel blocker (diltiazem). When you enter the room to assess Mrs. Blossom, her daughter looks at you concerned and says “mom’s acting kinda funny.”

What nursing assessments should be completed at this time?

• Full set of vital signs (Temp, HR, BP, RR, SpO2)
• Should probably get a 12-lead EKG
• Assess symptoms using PQRST or OLDCARTS

You assess Mrs. Blossom to find she has a left sided facial droop, slurred speech, and is unable to hold her left arm up for more than 3 seconds.

What is/are your priority nursing action(s) at this time?

• Call a Code Stroke (or whatever the equivalent is at your facility) to initiate response of the neurologist or Stroke team.
• Notify the charge nurse to help you obtain emergency equipment if you don’t already have it at the bedside to be prepared in case of emergency

What may be occurring in Mrs. Blossom?

• She may be having a stroke

You call a Code Stroke and notify the charge nurse for help. You obtain suction to have at bedside just in case. The neurologist arrives at bedside within 7 minutes to assess Mrs. Blossom. He notes her NIH Stroke Scale score is 32. He orders a STAT CT scan, which shows there is no obvious bleed in the brain.

What are the possible interventions for Mrs. Blossom at this time?

• Since there is no bleed evident on scan, Mrs. Blossom would qualify for a thrombolytic like tPA (alteplase) or for surgical intervention, as long as there are no contraindications

What are the contraindications for thrombolytics like tPA (alteplase)?

• Recent surgery, current or recent GI bleed within the last 3 months, excessive hypertension, evidence of cerebral hemorrhage

You administer tPA per protocol, initiate q15min vital signs and neuro checks. You stay with the patient to continue to monitor her symptoms.

What are possible complications of tPA administration? What should you monitor for?

• Bleeding, especially into the brain or a GI bleed
• She may bruise easily or bleed from IV sites or her gums
• Monitor for s/s bleeding or worsening stroke symptoms, which may indicate a hemorrhagic stroke has developed.

After 2 hours, Mrs. Blossom is showing signs of improvement. She is able to speak more clearly, though with a slight slur. She is still slightly weak on the left side, but is able to hold her arm up for 10 seconds now. Her NIHSS is now 6. Mrs. Blossom’s daughter asks you why this happened.

What would you explain has happened to Mrs. Blossom physiologically?

• Because of her new onset atrial fibrillation, the blood was likely pooling in her atria because they were just quivering and not contracting. When blood pools, it clots. When she was converted back into a normal rhythm and her atria began contracting again, that likely dislodged a clot, which went to her brain.
• The clot in her brain caused brain tissue to die → ischemic stroke.

Two days later, Mrs. Blossom has recovered fully. She will be discharged today on Clopidogrel and Aspirin, plus a calcium channel blocker,  with a follow up appointment in 1 week to see the neurologist.

What education topics should be included in the discharge teaching for Mrs. Blossom and her family?

• Anticoagulant therapy is imperative to prevent further clots from forming within Mrs. Blossom’s atria if she stays in Atrial Fibrillation.
• They should be taught the signs of a stroke (FAST) and call 911 if they notice them.
• They should be taught signs of Atrial Fibrillation with RVR and be sure to go to the hospital if this occurs – the patient is at higher risk for stroke.
• Medication instructions for calcium channel blockers and anticoagulants.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
• 7 Questions
• 5 Questions
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GI/GU Nursing Case Studies

• 2 Questions
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Obstetrics Nursing Case Studies

Respiratory nursing case studies.

• 10 Questions

Pediatrics Nursing Case Studies

• 3 Questions
• 12 Questions

Neuro Nursing Case Studies

Mental health nursing case studies.

• 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

Cerebrovascular Accident (Stroke)

Learn about the nursing care management of patients with cerebrovascular accident in this nursing study guide .

Table of Contents

• What is Cerebrovascular Accident? 

Classification

Risk factors, pathophysiology, statistics and epidemiology, clinical manifestations, complications, assessment and diagnostic findings, medical management, surgical management, nursing assessment, nursing diagnosis, nursing care planning & goals, nursing interventions, discharge and home care guidelines, documentation guidelines, what is cerebrovascular accident.

A cerebrovascular accident (CVA), an ischemic stroke or “ brain attack,” is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain.

• Cerebrovascular accident or stroke is the primary cerebrovascular disorder in the United States.
• A cerebrovascular accident is a sudden loss of brain functioning resulting from a disruption of the blood supply to a part of the brain.
• It is a functional abnormality of the central nervous system .
• Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
• The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory , speech, or sensation.

Strokes can be divided into two classifications.

• Ischemic stroke. This is the loss of function in the brain as a result of a disrupted blood supply.
• Hemorrhagic stroke. Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space.

The following are the nonmodifiable and modifiable risk factors of Cerebrovascular accident:

Nonmodifiable

• Advanced age (older than 55 years)
• Gender (Male)
• Race (African American)
• Hypertension
• Atrial fibrillation
• Hyperlipidemia
• Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic heart valves)
• Periodontal disease

The disruption in the blood flow initiates a complex series of cellular metabolic events.

• Decreased cerebral blood flow. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100g of blood per minute.
• Aerobic respiration. At this point, neurons are unable to maintain aerobic respiration.
• Anaerobic respiration. The mitochondria would need to switch to anaerobic respiration, which generates large amounts of lactic acid , causing a change in pH and rendering the neurons incapable of producing sufficient quantities of ATP.
• Loss of function. The membrane pumps that maintain electrolyte balances fail and the cells cease to function.

Stroke is a worldwide phenomenon suffered through all walks of life.

• Morbidity: In 2005, prevalence of stroke was estimated at 2.3 million males and 3.4 million females; many of the approximately 5.7 million U.S. stroke survivors have permanent stroke-related disabilities.
• Mortality: In 2004, stroke ranked fifth as the cause of death for those aged 45 to 64 years and third for those aged 65 years or older (National Heart, Lung and Blood Institute [NHLBI], 2007), with 150,000 deaths (American Heart Association and American Stroke Association, 2008); hemorrhagic strokes are more severe, and mortality rates are higher than ischemic strokes, with a 30-day mortality rate of 40% to 80%.
• Cost: Estimated direct and indirect cost for 2008 was $65.5 billion (American Heart Association and American Stroke Association, 2008).
• Stroke is the third leading cause of death after heart disease and cancer .
• Approximately 780, 000 people experience a stroke each year in the United States.
• Approximately 600, 000 of these are new strokes, and 180, 000 are recurrent strokes.
• About 5.6 million noninstitutionalized stroke survivors are alive today.
• Stroke is the leading cause of serious, long-term disability in the United States.
• Direct and indirect costs for stroke cost $65.5 billion in 2008.
• Strokes are usually hemorrhagic (15%) or ischemic/nonhemorrhagic (85%).
• Ischemic strokes are categorized according to their cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%).

Strokes are caused by the following:

• Large artery thrombosis . Large artery thromboses are caused by atherosclerotic plaques in the large blood vessels of the brain.
• Small penetrating artery thrombosis. Small penetrating artery thrombosis affects one or more vessels and is the most common type of ischemic stroke.
• Cardiogenic emboli. Cardiogenic emboli are associated with cardiac dysrhythmias, usually atrial fibrillation .

Stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion, the size of the area of inadequate perfusion, and the amount of the collateral blood flow. General signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of the body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty walking ; or sudden severe headache.

General signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of the body); confusion  or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty  walking ; or sudden severe headache.

• Numbness or weakness of the face. Without adequate perfusion, oxygen is also low, and facial tissues could not function properly without them.
• Change in mental status. Due to decreased oxygen, the patient experiences confusion .
• Trouble speaking or understanding speech. Cells cease to function as a result of inadequate perfusion.
• Visual disturbances. The eyes also need enough oxygen for optimal functioning.
• Homonymous hemianopsia. There is loss of half of the visual field.
• Loss of peripheral vision . The patient experiences difficulty seeing at night and is unaware of objects or the borders of objects.
• Hemiparesis. There is a weakness of the face, arm, and leg on the same side due to a lesion in the opposite hemisphere.
• Hemiplegia. Paralysis of the face, arm, and leg on the same side due to a lesion in the opposite hemisphere.
• Ataxia. Staggering, unsteady gait and inability to keep feet together.
• Dysarthria. This is the difficulty in forming words.
• Dysphagia . There is difficulty in swallowing.
• Paresthesia. There is numbness and tingling of extremities and difficulty with proprioception.
• Expressive aphasia . The patient is unable to form words that is understandable yet can speak in single-word responses.
• Receptive aphasia . The patient is unable to comprehend the spoken word and can speak but may not make any sense.
• Global aphasia. This is a combination of both expressive and receptive aphasia.
• Hemiplegia, hemiparesis
• Flaccid paralysis and loss of or decrease in the deep tendon reflexes (initial clinical feature) followed by (after 48 hours) reappearance of deep reflexes and abnormally increased muscle tone (spasticity)

Communication Loss

• Dysarthria (difficulty speaking)
• Dysphasia (impaired speech) or aphasia (loss of speech)
• Apraxia (inability to perform a previously learned action)

Perceptual Disturbances and Sensory Loss

• Visual-perceptual dysfunctions (homonymous hemianopia [loss of half of the visual field])
• Disturbances in visual-spatial relations (perceiving the relation of two or more objects in spatial areas), frequently seen in patients with right hemispheric damage
• Sensory losses: slight impairment of touch or more severe with loss of proprioception; difficulty in interrupting visual, tactile, and auditory stimuli

Impaired Cognitive and Psychological Effects

• Frontal lobe damage: Learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation.
• Depression , other psychological problems: emotional lability, hostility, frustration, resentment, and lack of cooperation.

Primary prevention of stroke remains the best approach.

• Healthy lifestyle. Leading a healthy lifestyle which includes not smoking, maintaining a healthy weight, following a healthy diet, and daily exercise can reduce the risk of having a stroke by about one half.
• DASH diet. The DASH ( Dietary Approaches to Stop Hypertension ) diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein and can lower the risk of stroke.
• Stroke risk screenings. Stroke risk screenings are an ideal opportunity to lower stroke risk by identifying people or groups of people who are at high risk for stroke.
• Education. Patients and the community must be educated about recognition and prevention of stroke.
• Low-dose aspirin . Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk.

If cerebral oxygenation is still inadequate; complications may occur.

• Tissue ischemia . If cerebral blood flow is inadequate, the amount of oxygen supplied to the brain is decreased, and tissue ischemia will result.
• Cardiac dysrhythmias. The heart compensates for the decreased cerebral blood flow, and with too much pumping, dysrhythmias may occur.

Any patient with neurologic deficits needs a careful history and complete physical and neurologic examination.

• CT scan . Demonstrates structural abnormalities, edema , hematomas, ischemia , and infarctions. Demonstrates structural abnormalities, edema , hematomas, ischemia, and infarctions. Note: May not immediately reveal all changes, e.g., ischemic infarcts are not evident on CT for 8–12 hr; however, intracerebral hemorrhage is immediately apparent; therefore, emergency CT is always done before administering tissue plasminogen activator (t-PA). In addition, patients with TIA commonly have a normal CT scan
• PET scan. Provides data on cerebral metabolism and blood flow changes.
• MRI. Shows areas of infarction, hemorrhage , AV malformations, and areas of ischemia.
• Cerebral angiography. Helps determine specific cause of stroke, e.g., hemorrhage or obstructed artery, pinpoints site of occlusion or rupture. Digital subtraction angiography evaluates patency of cerebral vessels, identifies their position in head and neck, and detects/evaluates lesions and vascular abnormalities.
• Lumbar puncture . Pressure is usually normal and CSF is clear in cerebral thrombosis, embolism, and TIA. Pressure elevation and grossly bloody fluid suggest subarachnoid and intracerebral hemorrhage. CSF total protein level may be elevated in cases of thrombosis because of inflammatory process. LP should be performed if septic embolism from bacterial endocarditis is suspected.
• Transcranial Doppler ultrasonography. Evaluates the velocity of blood flow through major intracranial vessels; identifies AV disease, e.g., problems with carotid system (blood flow/presence of atherosclerotic plaques).
• EEG. Identifies problems based on reduced electrical activity in specific areas of infarction; and can differentiate seizure activity from CVA damage.
• Skull x-ray. May show a shift of pineal gland to the opposite side from an expanding mass; calcifications of the internal carotid may be visible in cerebral thrombosis; partial calcification of walls of an aneurysm may be noted in subarachnoid hemorrhage.
• ECG and echocardiography .  To rule out cardiac origin as source of embolus (20% of strokes are the result of blood or vegetative emboli associated with valvular disease, dysrhythmias, or endocarditis).
• Laboratory studies to rule out systemic causes: CBC, platelet and clotting studies, VDRL/RPR, erythrocyte sedimentation rate (ESR), chemistries ( glucose , sodium ).

Patients who have experienced TIA or stroke should have medical management for secondary prevention.

• Recombinant tissue plasminogen activator would be prescribed unless contraindicated, and there should be monitoring for bleeding .
• Increased ICP. Management of increased ICP includes osmotic diuretics , maintenance of PaCO2 at 30-35 mmHg, and positioning to avoid hypoxia through elevation of the head of the bed.
• Endotracheal Tube. There is a possibility of intubation to establish patent airway if necessary.
• Hemodynamic monitoring. Continuous hemodynamic monitoring should be implemented to avoid an increase in blood pressure .
• Neurologic assessment to determine if the stroke is evolving and if other acute complications are developing

Surgical management may include prevention and relief from increased ICP.

• Carotid endarterectomy. This is the removal of atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.
• Hemicraniectomy. Hemicraniectomy may be performed for increased ICP from brain edema in severe cases of stroke.

Nursing Management

After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits.

During the acute phase , a neurologic flow sheet is maintained to provide data about the following important measures of the patient’s clinical status:

• Change in level of consciousness or responsiveness.
• Presence or absence of voluntary or involuntary movements of extremities.
• Stiffness or flaccidity of the neck.
• Eye opening, comparative size of pupils, and pupillary reaction to light.
• Color of the face and extremities; temperature and moisture of the skin.
• Ability to speak.
• Presence of bleeding.
• Maintenance of blood pressure .

During the postacute phase , assess the following functions:

• Mental status (memory, attention span, perception, orientation, affect, speech/language).
• Sensation and perception (usually the patient has decreased awareness of pain and temperature).
• Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration status, skin integrity, activity tolerance , and bowel and bladder function.
• Continue focusing nursing assessment on impairment of function in patient’s daily activities.

Based on the assessment data, the major nursing diagnoses for a patient with stroke may include the following:

• Impaired physical mobility related to hemiparesis, loss of balance and coordination , spasticity, and brain injury .
• Acute pain related to hemiplegia and disuse.
• Deficient self-care related to stroke sequelae.
• Disturbed sensory perception related to altered sensory reception, transmission, and/or integration.
• Impaired urinary elimination related to flaccid bladder , detrusor instability, confusion , or difficulty in communicating.
• Disturbed thought processes related to brain damage.
• Impaired verbal communication related to brain damage.
• Risk for impaired skin integrity related to hemiparesis or hemiplegia and decreased mobility .
• Interrupted family processes related to catastrophic illness and caregiving burdens.
• Sexual dysfunction related to neurologic deficits or fear of failure.

Main article: Cerebrovascular Accident (Stroke) Nursing Care Plans

The major nursing care planning goals for the patient and family may include:

• Improve mobility.
• Avoidance of shoulder pain .
• Achievement of self-care .
• Relief of sensory and perceptual deprivation.
• Prevention of aspiration .
• Continence of bowel and bladder.
• Improved thought processes.
• Achieving a form of communication .
• Maintaining skin integrity .
• Restore family functioning.
• Improve sexual function.
• Absence of complications.

Nursing care has a significant impact on the patient’s recovery. In summary, here are some nursing interventions for patients with stroke:

• Positioning. Position to prevent contractures, relieve pressure, attain good body alignment, and prevent compressive neuropathies.
• Prevent flexion . Apply splint at night to prevent flexion of the affected extremity.
• Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
• Prevent edema. Elevate affected arm to prevent edema and fibrosis.
• Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
• Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus .
• Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and begin walking as soon as standing balance is achieved.
• Personal hygiene . Encourage personal hygiene activities as soon as the patient can sit up.
• Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual perception is intact.
• Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in teaching alternate swallowing techniques.
• Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
• Be consistent in patient’s activities. Be consistent in the schedule, routines, and repetitions; a written schedule, checklists, and audiotapes may help with memory and concentration, and a communication board may be used.
• Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.

Improving Mobility and Preventing Deformities

• Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies.
• Apply a splint at night to prevent flexion of affected extremity.
• Prevent adduction of the affected shoulder with a pillow placed in the axilla.
• Elevate affected arm to prevent edema and fibrosis.
• Position fingers so that they are barely flexed; place hand in slight supination. If upper extremity spasticity is noted, do not use a hand roll; dorsal wrist splint may be used.
• Change position every 2 hours; place patient in a prone  position for 15 to 30 minutes several times a day.

Establishing an Exercise Program

• Provide full range of motion four or five times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. If tightness occurs in any area, perform a range of motion exercises more frequently.
• Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
• Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (e.g., shortness of breath, chest pain , cyanosis , and increasing pulse rate ).
• Supervise and support the patient during exercises; plan frequent short periods of exercise, not longer periods; encourage the patient to exercise unaffected side at intervals throughout the day.

Preparing for Ambulation

• Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is gone, when indicated).
• Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt table if needed).
• Begin walking as soon as standing balance is achieved (use parallel bars and have a wheelchair available in anticipation of possible dizziness).
• Keep training periods for ambulation short and frequent.

Preventing Shoulder Pain

• Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder.
• Use proper patient movement and positioning (e.g., flaccid arm on a table or pillows when patient is seated, use of sling when ambulating).
• Range of motion exercises are beneficial, but avoid over strenuous arm movements.
• Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as indicated.

Enhancing Self Care

• Encourage personal hygiene activities as soon as the patient can sit up; select suitable self-care activities that can be carried out with one hand.
• Help patient to set realistic goals; add a new task daily.
• As a first step, encourage patient to carry out all self-care activities on the unaffected side.
• Make sure patient does not neglect affected side; provide assistive devices as indicated.
• Improve morale by making sure patient is fully dressed during ambulatory activities.
• Assist with dressing activities (e.g., clothing with Velcro closures; put garment on the affected side first); keep environment uncluttered and organized.
• Provide emotional support and encouragement to prevent  fatigue and discouragement.

Managing Sensory-Perceptual Difficulties

• Approach patient with a decreased field of vision on the side where visual perception is intact; place all visual stimuli on this side.
• Teach patient to turn and look in the direction of the defective visual field to compensate for the loss; make eye contact with patient, and draw attention to affected side.
• Increase natural or artificial lighting in the room; provide eyeglasses to improve vision.
• Remind patient with hemianopsia of the other side of the body; place extremities so that patient can see them.

Assisting with Nutrition

• Observe patient for paroxysms of coughing , food dribbling out or pooling in one side of the mouth , food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
• Consult with speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing techniques, advise patient to take smaller boluses of food, and inform patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated.
• Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
• Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check tube position before feeding , administer feeding slowly, and ensure that cuff of tracheostomy tube is inflated (if applicable); monitor and report excessive retained or residual feeding .

Attaining Bowel and Bladder Control

• Perform intermittent sterile catheterization during the period of loss of sphincter control.
• Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
• Assist the male patient to an upright posture for voiding.
• Provide highfiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated.
• Establish a regular time (after breakfast) for toileting.

Improving Thought Processes

• Reinforce structured training program using cognitive, perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses.
• Support patient: Observe performance and progress, give positive feedback, convey an attitude of confidence and hopefulness; provide other interventions as used for improving cognitive function after a head injury.

Improving Communication

• Reinforce the individually tailored program.
• Jointly establish goals, with the patient taking an active part.
• Make the atmosphere conducive to communication , remaining sensitive to patient’s reactions and needs and responding to them in an appropriate manner; treat the patient as an adult.
• Provide strong emotional support and understanding to allay anxiety ; avoid completing patient’s sentences.
• Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may help with memory and concentration; a communication board may be used.
• Maintain patient’s attention when talking with the patient, speak slowly, and give one instruction at a time; allow the patient time to process.
• Talk to aphasic patients when providing care activities to provide social contact.

Maintaining Skin Integrity

• Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
• Employ pressure relieving devices; continue regular turning and positioning (every 2 hours minimally); minimize shear and friction when positioning.
• Keep skin clean and dry, gently massage the healthy dry skin and maintain adequate nutrition .

Improving Family Coping

• Provide counseling and support to the family.
• Involve others in patient’s care; teach stress management techniques and maintenance of personal health for family coping.
• Give family information about the expected outcome of the stroke, and counsel them to avoid doing things for the patient that he or she can do.
• Develop attainable goals for the patient at home by involving the total health care team, patient, and family.
• Encourage everyone to approach the patient with a supportive and optimistic attitude, focusing on abilities that remain; explain to the family that emotional lability usually improves with time.

Helping the Patient Cope with Sexual Dysfunction

• Perform indepth assessment to determine sexual history before and after the stroke.
• Interventions for patient and partner focus on providing relevant information, education, reassurance, adjustment
• of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a means of sexual expression and satisfaction.

Teaching points

• Teach patient to resume as much self care as possible; provide assistive devices as indicated.
• Have occupational therapist make a home assessment and recommendations to help the patient become more independent.
• Coordinate care provided by numerous health care professionals; help family plan aspects of care.
• Advise family that patient may tire easily, become irritable and upset by small events, and show less interest in daily events.
• Make a referral for home speech therapy. Encourage family involvement. Provide family with practical instructions to help patient between speech therapy sessions.
• Discuss patient’s depression with the physician for possible antidepressant therapy.
• Encourage patient to attend community-based stroke clubs to give a feeling of belonging and fellowship to others.
• Encourage patient to continue with hobbies, recreational and leisure interests, and contact with friends to prevent social isolation .
• Encourage family to support patient and give positive reinforcement.
• Remind spouse and family to attend to personal health and wellbeing.

Expected patient outcomes may include the following:

• Improved mobility.
• Absence of shoulder pain .
• Self-care achieved.
• Achieved a form of communication.
• Maintained skin integrity .
• Restored family functioning.
• Improved sexual function.

Patient and family education is a fundamental component of rehabilitation.

• Consult an occupational therapist. An occupational therapist may be helpful in assessing the home environment and recommending modifications to help the patient become more independent.
• Physical therapy. A program of physical therapy may be beneficial, whether it takes place in the home or in an outpatient program.
• Antidepressant therapy. Depression is a common and serious problem in the patient who has had a stroke.
• Support groups . Community-based stroke support groups may allow the patient and the family to learn from others with si milar problems and to share their experiences.
• Assess caregivers . Nurses should assess caregivers for signs of depression, as depression is also common among caregivers of stroke survivors.

The focus of documentation should involve:

• Individual findings including level of function and ability to participate in specific or desired activities.
• Needed resources and adaptive devices.
• Results of laboratory tests, diagnostic studies, and mental status or cognitive evaluation .
• SO/family support and participation.
• Plan of care and those involved in planning .
• Teaching plan.
• Response to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes .
• Modifications to plan of care.

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12 thoughts on “Cerebrovascular Accident (Stroke)”

I’m impressed, I have been challenged to read more.

The article was helpful

Am so impressed with the write up am student will wish to develop a research topic in CVA

As a nursing student, I want to thank this article for the valuable information on cerebrovascular accident nursing management. Understanding the importance of proper care and management for stroke patients is a crucial aspect of my education and future practice as a nurse. This article has provided me with a deeper insight into the role of the nurse in promoting positive outcomes for stroke patients, and I am grateful for the opportunity to learn more about this important topic. Thank you!

very presented alihamudulillah i got something

Hi Mugoya, Wonderful to hear you gained something valuable from the study guide! If you’re curious about more or have any questions, feel free to reach out. Always here to help!

well explained great article for students ……… Kindly increase the number of mcqs

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So interesting, very very good notes.

So interesting topic to learn

Excelente y completo artículo .muchas felicidades y gracias por la información

Very insightful. ⭐⭐⭐⭐

Can you add reference to the work.

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This presents an analysis of a case of Ischemic stroke in terms of possible etiology, pathophysiology, drug analysis and nursing care

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Ischemic stroke: A case study

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Chapter 7:  10 Real Cases on Transient Ischemic Attack and Stroke: Diagnosis, Management, and Follow-Up

Jeirym Miranda; Fareeha S. Alavi; Muhammad Saad

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Case 1: Management of Acute Thrombotic Cerebrovascular Accident Post Recombinant Tissue Plasminogen Activator Therapy

A 59-year-old Hispanic man presented with right upper and lower extremity weakness, associated with facial drop and slurred speech starting 2 hours before the presentation. He denied visual disturbance, headache, chest pain, palpitations, dyspnea, dysphagia, fever, dizziness, loss of consciousness, bowel or urinary incontinence, or trauma. His medical history was significant for uncontrolled type 2 diabetes mellitus, hypertension, hyperlipidemia, and benign prostatic hypertrophy. Social history included cigarette smoking (1 pack per day for 20 years) and alcohol intake of 3 to 4 beers daily. Family history was not significant, and he did not remember his medications. In the emergency department, his vital signs were stable. His physical examination was remarkable for right-sided facial droop, dysarthria, and right-sided hemiplegia. The rest of the examination findings were insignificant. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. The neurology team was consulted, and intravenous recombinant tissue plasminogen activator (t-PA) was administered along with high-intensity statin therapy. The patient was admitted to the intensive care unit where his hemodynamics were monitored for 24 hours and later transferred to the telemetry unit. MRI of the head revealed an acute 1.7-cm infarct of the left periventricular white matter and posterior left basal ganglia. How would you manage this case?

This case scenario presents a patient with acute ischemic cerebrovascular accident (CVA) requiring intravenous t-PA. Diagnosis was based on clinical neurologic symptoms and an NIHSS score of 7 and was later confirmed by neuroimaging. He had multiple comorbidities, including hypertension, diabetes, dyslipidemia, and smoking history, which put him at a higher risk for developing cardiovascular disease. Because his symptoms started within 4.5 hours of presentation, he was deemed to be a candidate for thrombolytics. The eligibility time line is estimated either by self-report or last witness of baseline status.

Ischemic strokes are caused by an obstruction of a blood vessel, which irrigates the brain mainly secondary to the development of atherosclerotic changes, leading to cerebral thrombosis and embolism. Diagnosis is made based on presenting symptoms and CT/MRI of the head, and the treatment is focused on cerebral reperfusion based on eligibility criteria and timing of presentation.

Symptoms include alteration of sensorium, numbness, decreased motor strength, facial drop, dysarthria, ataxia, visual disturbance, dizziness, and headache.

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Statement of ethics, conflict of interest statement, funding sources, author contributions, ischemic stroke in a 29-year-old patient with covid-19: a case report.

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Christian Avvantaggiato , Loredana Amoruso , Maria Pia Lo Muzio , Maria Assunta Mimmo , Michelina Delli Bergoli , Nicoletta Cinone , Luigi Santoro , Lucia Stuppiello , Antonio Turitto , Chiara Ciritella , Pietro Fiore , Andrea Santamato; Ischemic Stroke in a 29-Year-Old Patient with COVID-19: A Case Report. Case Rep Neurol 2 September 2021; 13 (2): 334–340. https://doi.org/10.1159/000515457

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Increasing evidence reports a greater incidence of stroke among patients with Coronavirus disease 2019 (COVID-19) than the non-COVID-19 population and suggests that SARS-CoV-2 infection represents a risk factor for thromboembolic and acute ischemic stroke. Elderly people have higher risk factors associated with acute ischemic stroke or embolization vascular events, and advanced age is strongly associated with severe COVID-19 and death. We reported, instead, a case of an ischemic stroke in a young woman during her hospitalization for COVID-19-related pneumonia. A 29-year-old woman presented to the emergency department of our institution with progressive respiratory distress associated with a 2-day history of fever, nausea, and vomiting. The patient was transferred to the intensive care unit (ICU) where she underwent a tracheostomy for mechanical ventilation due to her severe clinical condition and her very low arterial partial pressure of oxygen. The nasopharyngeal swab test confirmed SARS-CoV-2 infection. Laboratory tests showed neutrophilic leucocytosis, a prolonged prothrombin time, and elevated D-dimer and fibrinogen levels. After 18 days, during her stay in the ICU after suspension of the medications used for sedation, left hemiplegia was reported. Central facial palsy on the left side, dysarthria, and facial drop were present, with complete paralysis of the ipsilateral upper and lower limbs. Computed tomography (CT) of the head and magnetic resonance imaging of the brain confirmed the presence of lesions in the right hemisphere affecting the territories of the anterior and middle cerebral arteries, consistent with ischemic stroke. Pulmonary and splenic infarcts were also found after CT of the chest. The age of the patient and the absence of serious concomitant cardiovascular diseases place the emphasis on the capacity of SARS-CoV-2 infection to be an independent cerebrovascular risk factor. Increased levels of D-dimer and positivity to β2-glycoprotein antibodies could confirm the theory of endothelial activation and hypercoagulability, but other mechanisms – still under discussion – should not be excluded.

Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, is characterized by a wide range of symptoms, most of which cause acute respiratory distress syndrome [1, 2], associated with intensive care unit (ICU) admission and high mortality [3]. On March 11, 2020, the large global outbreak of the disease led the World Health Organization (WHO) to declare COVID-19 a pandemic, with 11,874,226 confirmed cases and 545,481 deaths worldwide (July 9, 2020) [4]. In many cases, the clinical manifestations of COVID-19 are characteristic of a mild disease that may, however, worsen to a critical lower respiratory infection [2]. At the onset of the disease, the most frequent symptoms are fever, dry cough, fatigue, and shortness of breath as the infection progresses may appear signs and symptoms of respiratory failure that require ICU admission [5, 6]. Although acute respiratory distress syndrome is the most important cause of ICU admission for COVID-19 patients, several studies have underlined the presence of neurological symptoms such as confusion, dizziness, impaired consciousness, ataxia, seizure, anosmia, ageusia, vision impairment, and stroke [7, 8]. In particular, the state of hypercoagulability in patients affected by COVID-19 favors the formation of small and/or large blood clots in multiple organs, including the brain, potentially leading to cerebrovascular disease (ischemic stroke but also intracranial hemorrhage) [9, 10 ].

We found an interesting case of stroke following a SARS-CoV-2 infection in a young patient. A 29-year-old woman, during her ICU hospitalization for COVID-19-related pneumonia, was diagnosed with ischemic stroke of the right hemisphere, without other cardiac/cerebrovascular risk factors except hypertension. The young age of the patient and the absence of higher cerebrovascular risk factors make the present case very interesting as it can help demonstrate that COVID-19 is an independent risk factor for acute ischemic stroke. In a case series of 214 patients with COVID-19 (mean [SD] age, 52.7 [15.5] years), neurologic symptoms were more common in patients with severe infection who were older than the others [ 11 ]. New-onset CVD was more common in COVID-19 patients who had underlying cerebrovascular risk factors, such as older age (>65 years) [ 12 ], and very few cases of stroke in patients younger than 50 years have been reported [ 12, 13 ]. Our case seems to be the only one younger than 30 years.

On the night between March 19 and 20, 2020, a 29-year-old woman was referred to our hospital “Policlinico Riuniti di Foggia” due to a progressive respiratory distress associated with a 2-day history of fever, nausea, and vomiting. At presentation, the heart rate was 128 bpm, the blood oxygen saturation measured by means of the pulse oximeter was 27%, the respiratory rate was 27 breaths per minute, and the blood pressure was 116/77 mm Hg. The arterial blood gas test showed a pH of 7.52, pO 2 20 mm Hg, and pCO 2 34 mm Hg. The patient was immediately transferred to the ICU where she underwent tracheostomy and endotracheal intubation for mechanical ventilation due to her severe clinical condition and deteriorated pulmonary gas exchange. The diagnosis of COVID-19 was confirmed by PCR on a nasopharyngeal swab.

The family medical history was normal, and the only known pre-existing medical conditions were polycystic ovary syndrome (diagnosed 3 years earlier), conversion disorder, and hypertension (both diagnosed 2 years earlier). Ramipril and nebivolol were prescribed for the high blood pressure treatment, and sertraline was prescribed for the conversion disorder treatment. Drug therapy adherence was inconstant. The patient had no history of diabetes, cardiac pathologies, strokes, transient ischemic attacks, thromboembolic, or other vascular pathologies.

Laboratory tests showed neutrophilic leukocytosis (white blood cell count 14.79 × 10 3 , neutrophil percentage 89.8%, and neutrophil count 13.29 × 10 3 ), a prolonged prothrombin time (15.3 s) with a slightly elevated international normalized ratio (1.38), and elevated D-dimer (6,912 ng/mL) and fibrinogen levels (766 mg/dL). Other findings are shown in Table  1 .

Laboratory test

This pharmacological therapy was set as follows: enoxaparin 6,000 U.I. once a day, piperacillin 4 g/tazobactam 0.5 g twice a day; Kaletra, a combination of lopinavir and ritonavir indicated for human immunodeficiency virus (HIV) infection treatment, 2 tablets twice a day; hydroxychloroquine 200 mg once a day; and furosemide 250 mg, calcium gluconate, and aminophylline 240 mg 3 times a day. No adverse events were reported.

On April 7, 2020, during her stay in the ICU and after suspension of the medications used for sedation, left hemiplegia was reported. The same day, the patient underwent a computed tomography examination of the head, which showed areas of hypodensity in the right hemisphere due to recent cerebral ischemia.

On April 16, 2020, the patient was oriented to time, place, and person. Central facial palsy on the left side, dysarthria, and facial drop were present, with complete paralysis of the ipsilateral upper and lower limbs. The power of all the muscles of the left limbs was grade 0 according to the Medical Research Council (MRC) scale. Deep tendon reflexes were reduced on the left upper limb but hyperactive on the ipsilateral lower limb, with a slight increase in the muscle tonus. The senses of touch, vibration, and pain were reduced on the left side of the face and body.

On the same day, the patient underwent magnetic resonance imaging (MRI) of the brain (Fig.  1 a), showing lesions on the right hemisphere affecting the territories of the anterior and middle cerebral arteries. On May 5, 2020, magnetic resonance angiography showed an early duplication of the sphenoidal segment of the right middle cerebral artery, the branches of which are irregular with rosary bead-like aspects (Fig.  1 d, e); on the same day, the second MRI (Fig.  1 b) confirmed the lesions. Computed tomography of the chest (Fig.  1 c) and abdomen (Fig.  1 f), performed 5 days after the MRI of the brain, showed not only multifocal bilateral ground-glass opacities but also a basal subpleural area of increased density within the left lung (4 × 4 × 3 cm), consistent with a pulmonary infarction. In addition, a vascular lesion, consistent with a splenic infarct, was found in the inferior pole of the spleen. Doppler echocardiography of the hearth showed regular right chambers and left atrium and a slightly hypertrophic left ventricle with normal size and kinetics (ejection fraction: 55%). The age of the patient and the absence of serious concomitant cardiovascular diseases place the emphasis on the capacity of SARS-CoV-2 infection to be an independent cerebrovascular risk factor.

Imaging. a April 16, 2020; MRI of the brain: lesions in the right hemisphere affecting the territories of the anterior and the middle cerebral arteries. b May 5, 2020; MRI of the brain: same lesions in the right hemisphere shown in the previous image. d , e May 5, 2020; MRA showed an early duplication of the sphenoidal segment of the right middle cerebral artery, the branches of which are irregular with rosary bead-like aspect and reduction of blood flow in the middle cerebral artery. c April 20, 2020; CT of the abdomen: vascular lesion, consistent with a splenic infarct, found in the inferior pole of the spleen. f April 20, 2020; CT of the chest: basal subpleural area of increased density within the left lung (4 × 4 × 3 cm), consistent with a pulmonary infarction. MRA, magnetic resonance angiography; CT, computed tomography; MRI, magnetic resonance imaging.

The pandemic outbreak of novel SARS-CoV-2 infection has caused great concern among the services and authorities responsible for public health due to not only the mortality rate but also the danger of filling up hospital capacities in terms of ICU beds and acute non-ICU beds. In this regard, the nonrespiratory complications of COVID-19 should also be taken into great consideration, especially those that threaten patients’ lives and extend hospitalization times. Stroke is one of these complications, since a greater incidence of stroke among patients with COVID-19 than the non-COVID-19 population has been reported, and a preliminary case-control study demonstrated that SARS-CoV-2 infection represents a risk factor for acute ischemic stroke [ 14 ].

We found that the reported case is extremely interesting, since the woman is only 29 years old and considering how stroke in a young patient without other known risk factors is uncommon. Not only elderly people have higher risk factors associated with acute ischemic stroke or embolization vascular events [ 15 ], but it is also true that advanced age is strongly associated with severe COVID-19 and death. The severity of the disease is directly linked to immune dysregulation, cytokine storm, and acute inflammation state, which in turn are more common in patients who present immunosenescence [6].

Inflammation plays an important role in the occurrence of cardiovascular and cerebrovascular diseases since it favors atherosclerosis and affects plaque stability [ 16 ]. The ischemic stroke of the 29-year-old woman does not appear to be imputable to emboli originating a pre-existing atheromatous plaque, both for the age of the patient and for the absence of plaques at the Doppler ultrasound study of the supra-aortic trunks.

Most likely, COVID-19-associated hypercoagulability and endothelial dysfunction are the causes of ischemic stroke, as suggested by other studies and case reports [ 10, 13, 17 ]. Although the mechanisms by which SARS-CoV-2 infection leads to hypercoagulability are still being studied, current knowledge suggests that cross talk between inflammation and thrombosis has a crucial role [ 18 ]. The release of inflammatory cytokines leads to the activation of epithelial cells, monocytes, and macrophages. Direct infection of endothelial cells through the ACE2 receptor also leads to endothelial activation and dysfunction, expression of tissue factor, and platelet activation and increased levels of VWF and FVIII, all of which contribute to thrombin generation and fibrin clot formation [ 17 ]. The 29-year-old patient showed an increased level of D-dimer, which is a degradation product of cross-linked fibrin, indicating a global activation of hemostasis and fibrinolysis and conforming to the hypothesis of COVID-19-associated hypercoagulability. Endothelial activation and hypercoagulability are also confirmed by positivity to β2 glycoprotein antibodies. Anticardiolipin antibody and/or β2 glycoprotein antibody positivity has been reported in a few studies [ 17, 19, 20 ]. In addition, widespread thrombosis in SARS-CoV-2 infection could also be caused by neutrophil extracellular traps (NETs). Neutrophilia [ 21 ] and an elevated neutrophil-lymphocyte ratio [ 22 ] have been reported by numerous studies as predictive of worse disease outcomes, and recently, the contribution of NETs in the pathophysiology of COVID-19 was reported [ 23 ]. Thrombogenic involvement of NETs has been described in various settings of thrombosis, including stroke, myocardial infarction, and deep vein thrombosis [ 24 ]. The high neutrophil count found in our case does not exclude the hypothesis that NETs are involved in the pathogenesis of ischemic stroke.

Ischemic stroke in young patients without pre-existing cerebrovascular risk factors is very unusual. In this regard, our case of an ischemic stroke, reported in a 29-year-old woman, is very interesting. Although it is not possible to determine precisely when the thromboembolic event occurred, our case of stroke during COVID-19-related pneumonia seems to confirm that COVID-19 is an independent risk factor for acute ischemic stroke. The mechanisms by which coronavirus disease leads to stroke are still under study, but it is clear that hypercoagulability and endothelial activation play a key role. Testing for SARS-CoV-2 infection should be considered for patients who develop neurologic symptoms, but it is equally important to monitor COVID-19 patients during their hospitalization to find any neurological sign or symptom in a timely manner. Our case suggests that discovering neurological deficits in sedated patients promptly can be very difficult; for this reason, sedation in mechanically ventilated patients has to be considered only if strictly necessary. Performing serial laboratory testing and waking up the patient as soon as clinical conditions allow are strategies that should be taken into account.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.

The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

No funding was received for the publication of this case report.

All authors agree with the contents of the manuscript and were fully involved in the study and preparation of the manuscript. All authors read and approved the final version of the manuscript. M.A. Mimmo, M.P. Lo Muzio, M. Delli Bergoli, and L. Amoruso collected the data. C. Avvantaggiato wrote the manuscript with support of N. Cinone, L. Santoro, and C. Ciritella. C. Avvantaggiato, A. Turitto, and L. Stuppiello researched and discussed the neurophysiological principles of this study. P. Fiore and A. Santamato supervised the project.

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Ischemic Stroke

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Patient M is an active woman, 70 years of age, who lost consciousness and collapsed at home. Her daughter, who was visiting her at the time, did not witness the collapse but found her mother on the floor, awake, confused, and slightly short of breath. The daughter estimated that she called EMS within 5 minutes after the collapse, and EMS responded within 15 minutes. EMS evaluated Patient M, drew blood for a glucose level, and determined that she may have had a stroke. They notified the nearest designated comprehensive stroke center that they would be arriving with the patient in approximately 20 minutes. Patient M's daughter accompanied her.

The triage and transportation of an individual with suspected stroke should be similar to that for an individual with serious trauma, and treatment is recommended within 3 hours after the onset of stroke. Because of the limited time available for assessment and diagnosis before optimal treatment, the EMS dispatcher should notify EMS personnel immediately and coordinate transport of the individual to the closest emergency facility, preferably one that is a designated primary (or comprehensive) stroke care center.

On presentation in the emergency department, Patient M is immediately triaged. Because Patient M is still somewhat confused, her daughter is asked to provide information on the patient's history. The daughter reports that her mother had had an episode of sudden-onset numbness and tingling in the right limb, with slight confusion and slurred speech, 3 days previously. The episode lasted only 5 minutes, and Patient M had not called her primary care physician. Additional information provided by the daughter indicates that Patient M has been treated for hypertension for 10 years but notes that she is often not compliant with her antihypertensive medicine, a diuretic. The patient has never smoked, drinks occasionally, and is of normal weight.

Patient M has two significant risk factors for stroke; one is a long history of hypertension. More than two-thirds of individuals older than 65 years of age are hypertensive, and it is important for individuals with hypertension to have regular blood pressure screening and to maintain a blood pressure of less than 140/90 mm Hg. Antihypertension therapy has been found to reduce the incidence of stroke by 30% to 40%. Patient M's noncompliance with her antihypertension medicine likely includes her among the 65% of known hypertensive individuals in whom blood pressure is not controlled.

Patient M's previous episode of numbness, confusion, and slurred speech appears to be evidence of a TIA, another substantial risk factor for stroke. Research has shown that approximately 5% of patients will have an ischemic stroke within 7 days after a TIA. In addition, the risk of stroke within 7 days is doubled for patients with TIAs who did not seek treatment. As is the case for many individuals who have a TIA, Patient M did not seek medical attention because the clinical symptoms resolved quickly. However, research findings indicate that urgent treatment should be provided for TIAs, as early treatment for TIA and minor stroke has been shown to reduce the risk of early recurrent stroke by 80%.

On physical examination, Patient M's blood pressure is 150/95 mm Hg. She has pain in her left arm and a slight headache. There is a focal carotid bruit on the right. She is assessed with use of the NIHSS and found to have 1/5 weakness in the left upper and lower extremities and left visual/spatial neglect. The results of laboratory tests, including a complete blood count, prothrombin time, serum electrolyte levels, cardiac biomarkers, and renal function studies, are all within normal limits. CT of the head obtained about 45 minutes into her ED evaluation (1.5 to 2 hours since last well) indicates an occlusion in a branch of the right internal carotid artery with 50% narrowing due to atherosclerosis. An area of ischemia/infarction is visible in the right anterior cerebral hemisphere. There is no evidence of subarachnoid hemorrhage. Approximately 2.5 to 3 hours after Patient M collapsed at home, she is treated with IV rt-PA at a dose of 0.9 mg/kg. Twenty-four hours later, aspirin antiplatelet therapy is started at an initial dose of 325 mg, and a maintenance dose of 75 mg per day.

Many of the patient's symptoms, including her loss of consciousness, shortness of breath, pain, and headache, are nontraditional symptoms of stroke. Studies have demonstrated that nontraditional symptoms are more prevalent among women, often leading to a delay in the evaluation for stroke. EMS personnel and clinicians should be aware of the potential for nontraditional symptoms in women and carry out a diagnostic evaluation addressing a suspicion of stroke.

Patient M is eligible for thrombolytic therapy with rt-PA according to evidence-based guidelines developed by the AHA/ASA: her blood pressure is lower than 185/110 mm Hg, the onset of symptoms is less than 3 hours prior to the start of treatment, and the laboratory values are within normal limits. Antiplatelet therapy with aspirin 325 mg daily (versus anticoagulant therapy with warfarin) is recommended for treatment of patients with stroke or TIA due to intracranial atherosclerosis with 50% to 99% occlusion. Antiplatelet therapy is not recommended as an adjunctive therapy within 24 hours of thrombolytic therapy.

When Patient M's condition is stabilized, her primary care physician and consultant neurologist provide a referral for stroke rehabilitation, and a multidisciplinary rehabilitation team is formed to assess her rehabilitative needs, recommend the proper rehabilitation setting, and develop a treatment strategy tailored to her specific needs that includes daily antiplatelet therapy. Patient M is again assessed with the NIHSS, and the score is 12. The patient's cognitive and communication skills are intact on evaluation with the FIM, with the exception of the previously documented left visual/spatial neglect. The assessment also includes evaluation of the patient's risk for complications. Because of her spatial neglect, she is screened with the Berg Balance Scale and the Stops Walking When Talking test. The score on the Berg Balance Scale is 43, and Patient M does stop walking to engage in conversation. Psychosocial assessment includes screening with the Center for Epidemiologic Studies Depression (CES-D) Scale, as well as review of the medical history and conversations with the patient and her children; no signs of depression are present.

Patient M's score of 12 on the NIHSS falls within the range (6 to 15) that indicates she is likely to benefit from rehabilitation. Evaluating a stroke survivor's risk of complications is an important component of the overall assessment, and among the most common complications are falls, deep vein thrombosis, pressure ulcers, swallowing dysfunction, bladder and bowel dysfunction, and depressive symptoms. In assessing the risk of complications, the Berg Balance Scale appears to be the most appropriate screen for patients who are likely to fall, and a score of less than 45 is associated with a likelihood of falling. The risk of a fall is also increased when a patient stops walking to talk, as Patient M did, during the Stops Talking When Walking test.

Screening for signs of depression is also essential, as depression affects approximately 33% of stroke survivors. Signs of depression are subtle and may be vague. Several screening tools are available, but there is no universally accepted tool for use in the post-stroke setting. The CES-D was chosen in this case because it is easy to administer, is useful in older individuals, and has been found to be effective for screening in the stroke population, except for individuals who have aphasia. The diagnosis of depression in stroke survivors should be based on sources in addition to a formal screening tool, such as a medical evaluation, patient self-report, observation of patient behavior, patient history, and staff reports of changes in behavior and motivation.

The rehabilitation team discusses the results of the assessment with Patient M's daughter and son, both of whom live about 45 minutes away from the patient. Together, the team and the family members explore options to determine the best approach to rehabilitation. A decision is made to transfer Patient M to an inpatient stroke unit, and a rehabilitation program is developed. The nurse on the team discusses the program with Patient M and her children and explains the course of rehabilitation and the expectations. Rehabilitation will focus on an exercise program consisting of aerobic exercise, strength training, stretching, and coordination and balance activities.

Early initiation of rehabilitation is a particularly strong predictor of improved outcome, and rehabilitation in a stroke unit has been associated with improved quality of life, survival, and functional status at 5 years compared with a general healthcare facility. No studies have demonstrated the superiority of one rehabilitation setting over another, and the inpatient setting was chosen primarily to ensure consistent care, given how far away Patient M's children live, and the limited support she otherwise has for healthcare needs. Decisions about the setting and program for rehabilitation should be shared with family members, and family and other caregivers should be provided with educational resources about the rehabilitation process.

The exercise program developed for Patient M is designed to help her regain the ability to independently carry out activities of daily living safely and to regain a functional level of ambulation. The benefits of an exercise program include increasing fitness, strength, and flexibility; improving function; preventing injuries and falls; and reducing the risk of recurrent stroke.

Patient M gradually resumes the ability to function independently, and after more than 2 weeks in the stroke rehabilitation unit, the score on the NIHSS has improved to 5. Before she is discharged to her home, the rehabilitation team provides instructions for exercises to continue at home and recommends moderate physical activity as a secondary prevention measure. The team also educates Patient M about the importance of maintaining a normal blood pressure through use of her antihypertension medication and lifestyle modifications. At a follow-up visit with her primary care clinician at 3 months, Patient M's blood pressure is 135/80 mm Hg, and she reports that she has been compliant with her antihypertension medicine and antiplatelet therapy and is functioning well at home.

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• Clinical course of a 66-year-old man with an acute ischaemic stroke in the setting of a COVID-19 infection
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• http://orcid.org/0000-0002-7441-6952 Saajan Basi 1 , 2 ,
• Mohammad Hamdan 1 and
• Shuja Punekar 1
• 1 Department of Stroke and Acute Medicine , King's Mill Hospital , Sutton-in-Ashfield , UK
• 2 Department of Acute Medicine , University Hospitals of Derby and Burton , Derby , UK
• Correspondence to Dr Saajan Basi; saajan.basi{at}nhs.net

A 66-year-old man was admitted to hospital with a right frontal cerebral infarct producing left-sided weakness and a deterioration in his speech pattern. The cerebral infarct was confirmed with CT imaging. The only evidence of respiratory symptoms on admission was a 2 L oxygen requirement, maintaining oxygen saturations between 88% and 92%. In a matter of hours this patient developed a greater oxygen requirement, alongside reduced levels of consciousness. A positive COVID-19 throat swab, in addition to bilateral pneumonia on chest X-ray and lymphopaenia in his blood tests, confirmed a diagnosis of COVID-19 pneumonia. A proactive decision was made involving the patients’ family, ward and intensive care healthcare staff, to not escalate care above a ward-based ceiling of care. The patient died 5 days following admission under the palliative care provided by the medical team.

• respiratory medicine
• infectious diseases
• global health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bcr-2020-235920

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SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is a new strain of coronavirus that is thought to have originated in December 2019 in Wuhan, China. In a matter of months, it has erupted from non-existence to perhaps the greatest challenge to healthcare in modern times, grinding most societies globally to a sudden halt. Consequently, the study and research into SARS-CoV-2 is invaluable. Although coronaviruses are common, SARS-CoV-2 appears to be considerably more contagious. The WHO figures into the 2003 SARS-CoV-1 outbreak, from November 2002 to July 2003, indicate a total of 8439 confirmed cases globally. 1 In comparison, during a period of 4 months from December 2019 to July 2020, the number of global cases of COVID-19 reached 10 357 662, increasing exponentially, illustrating how much more contagious SARS-CoV-2 has been. 2

Previous literature has indicated infections, and influenza-like illness have been associated with an overall increase in the odds of stroke development. 3 There appears to be a growing correlation between COVID-19 positive patients presenting to hospital with ischaemic stroke; however, studies investigating this are in progress, with new data emerging daily. This patient report comments on and further characterises the link between COVID-19 pneumonia and the development of ischaemic stroke. At the time of this patients’ admission, there were 95 positive cases from 604 COVID-19 tests conducted in the local community, with a predicted population of 108 000. 4 Only 4 days later, when this patient died, the figure increased to 172 positive cases (81% increase), illustrating the rapid escalation towards the peak of the pandemic, and widespread transmission within the local community ( figure 1 ). As more cases of ischaemic stroke in COVID-19 pneumonia patients arise, the recognition and understanding of its presentation and aetiology can be deciphered. Considering the virulence of SARS-CoV-2 it is crucial as a global healthcare community, we develop this understanding, in order to intervene and reduce significant morbidity and mortality in stroke patients.

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A graph showing the number of patients with COVID-19 in the hospital and in the community over time.

Case presentation

A 66-year-old man presented to the hospital with signs of left-sided weakness. The patient had a background of chronic obstructive pulmonary disease (COPD), atrial fibrillation and had one previous ischaemic stroke, producing left-sided haemiparesis, which had completely resolved. He was a non-smoker and lived in a house. The patient was found slumped over on the sofa at home on 1 April 2020, by a relative at approximately 01:00, having been seen to have no acute medical illness at 22:00. The patients’ relative initially described disorientation and agitation with weakness noted in the left upper limb and dysarthria. At the time of presentation, neither the patient nor his relative identified any history of fever, cough, shortness of breath, loss of taste, smell or any other symptoms; however, the patient did have a prior admission 9 days earlier with shortness of breath.

The vague nature of symptoms, entwined with considerable concern over approaching the hospital, due to the risk of contracting COVID-19, created a delay in the patients’ attendance to the accident and emergency department. His primary survey conducted at 09:20 on 1 April 2020 demonstrated a patent airway, with spontaneous breathing and good perfusion. His Glasgow Coma Scale (GCS) score was 15 (a score of 15 is the highest level of consciousness), his blood glucose was 7.2, and he did not exhibit any signs of trauma. His abbreviated mental test score was 7 out of 10, indicating a degree of altered cognition. An ECG demonstrated atrial fibrillation with a normal heart rate. His admission weight measured 107 kg. At 09:57 the patient required 2 L of nasal cannula oxygen to maintain his oxygen saturations between 88% and 92%. He started to develop agitation associated with an increased respiratory rate at 36 breaths per minute. On auscultation of his chest, he demonstrated widespread coarse crepitation and bilateral wheeze. Throughout he was haemodynamically stable, with a systolic blood pressure between 143 mm Hg and 144 mm Hg and heart rate between 86 beats/min and 95 beats/min. From a neurological standpoint, he had a mild left facial droop, 2/5 power in both lower limbs, 2/5 power in his left upper limb and 5/5 power in his right upper limb. Tone in his left upper limb had increased. This patient was suspected of having COVID-19 pneumonia alongside an ischaemic stroke.

Investigations

A CT of his brain conducted at 11:38 on 1 April 2020 ( figure 2 ) illustrated an ill-defined hypodensity in the right frontal lobe medially, with sulcal effacement and loss of grey-white matter. This was highly likely to represent acute anterior cerebral artery territory infarction. Furthermore an oval low-density area in the right cerebellar hemisphere, that was also suspicious of an acute infarction. These vascular territories did not entirely correlate with his clinical picture, as limb weakness is not as prominent in anterior cerebral artery territory ischaemia. Therefore this left-sided weakness may have been an amalgamation of residual weakness from his previous stroke, in addition to his acute cerebral infarction. An erect AP chest X-ray with portable equipment ( figure 3 ) conducted on the same day demonstrated patchy peripheral consolidation bilaterally, with no evidence of significant pleural effusion. The pattern of lung involvement raised suspicion of COVID-19 infection, which at this stage was thought to have provoked the acute cerebral infarct. Clinically significant blood results from 1 April 2020 demonstrated a raised C-reactive protein (CRP) at 215 mg/L (normal 0–5 mg/L) and lymphopaenia at 0.5×10 9 (normal 1×10 9 to 3×10 9 ). Other routine blood results are provided in table 1 .

CT imaging of this patients’ brain demonstrating a wedge-shaped infarction of the anterior cerebral artery territory.

Chest X-ray demonstrating the bilateral COVID-19 pneumonia of this patient on admission.

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Clinical biochemistry and haematology blood results of the patient

Interestingly the patient, in this case, was clinically assessed in the accident and emergency department on 23 March 2020, 9 days prior to admission, with symptoms of shortness of breath. His blood results from this day showed a CRP of 22 mg/L and a greater lymphopaenia at 0.3×10 9 . He had a chest X-ray ( figure 4 ), which indicated mild radiopacification in the left mid zone. He was initially treated with intravenous co-amoxiclav and ciprofloxacin. The following day he had minimal symptoms (CURB 65 score 1 for being over 65 years). Given improving blood results (declining CRP), he was discharged home with a course of oral amoxicillin and clarithromycin. As national governmental restrictions due to COVID-19 had not been formally announced until 23 March 2020, and inconsistencies regarding personal protective equipment training and usage existed during the earlier stages of this rapidly evolving pandemic, it is possible that this patient contracted COVID-19 within the local community, or during his prior hospital admission. It could be argued that the patient had early COVID-19 signs and symptoms, having presented with shortness of breath, lymphopaenia, and having had subtle infective chest X-ray changes. The patient explained he developed a stagnant productive cough, which began 5 days prior to his attendance to hospital on 23 March 2020. He responded to antibiotics, making a full recovery following 7 days of treatment. This information does not assimilate with the typical features of a COVID-19 infection. A diagnosis of community-acquired pneumonia or infective exacerbation of COPD seem more likely. However, given the high incidence of COVID-19 infections during this patients’ illness, an exposure and early COVID-19 illness, prior to the 23 March 2020, cannot be completely ruled out.

Chest X-ray conducted on prior admission illustrating mild radiopacification in the left mid zone.

On the current admission, this patient was managed with nasal cannula oxygen at 2 L. By the end of the day, this had progressed to a venturi mask, requiring 8 L of oxygen to maintain oxygen saturation. He had also become increasingly drowsy and confused, his GCS declined from 15 to 12. However, the patient was still haemodynamically stable, as he had been in the morning. An arterial blood gas demonstrated a respiratory alkalosis (pH 7.55, pCO 2 3.1, pO 2 6.7 and HCO 3 24.9, lactate 1.8, base excess 0.5). He was commenced on intravenous co-amoxiclav and ciprofloxacin, to treat a potential exacerbation of COPD. This patient had a COVID-19 throat swab on 1 April 2020. Before the result of this swab, an early discussion was held with the intensive care unit staff, who decided at 17:00 on 1 April 2020 that given the patients presentation, rapid deterioration, comorbidities and likely COVID-19 diagnosis he would not be for escalation to the intensive care unit, and if he were to deteriorate further the end of life pathway would be most appropriate. The discussion was reiterated to the patients’ family, who were in agreement with this. Although he had evidence of an ischaemic stroke on CT of his brain, it was agreed by all clinicians that intervention for this was not as much of a priority as providing optimal palliative care, therefore, a minimally invasive method of treatment was advocated by the stroke team. The patient was given 300 mg of aspirin and was not a candidate for fibrinolysis.

Outcome and follow-up

The following day, before the throat swab result, had appeared the patient deteriorated further, requiring 15 L of oxygen through a non-rebreather face mask at 60% FiO 2 to maintain his oxygen saturation, at a maximum of 88% overnight. At this point, he was unresponsive to voice, with a GCS of 5. Although, he was still haemodynamically stable, with a blood pressure of 126/74 mm Hg and a heart rate of 98 beats/min. His respiratory rate was 30 breaths/min. His worsening respiratory condition, combined with his declining level of consciousness made it impossible to clinically assess progression of the neurological deficit generated by his cerebral infarction. Moreover, the patient was declining sharply while receiving the maximal ward-based treatment available. The senior respiratory physician overseeing the patients’ care decided that a palliative approach was in this his best interest, which was agreed on by all parties. The respiratory team completed the ‘recognising dying’ documentation, which signified that priorities of care had shifted from curative treatment to palliative care. Although the palliative team was not formally involved in the care of the patient, the patient received comfort measures without further attempts at supporting oxygenation, or conduction of regular clinical observations. The COVID-19 throat swab confirmed a positive result on 2 April 2020. The patient was treated by the medical team under jurisdiction of the hospital palliative care team. This included the prescribing of anticipatory medications and a syringe driver, which was established on 3 April 2020. His antibiotic treatment, non-essential medication and intravenous fluid treatment were discontinued. His comatose condition persisted throughout the admission. Once the patients’ GCS was 5, it did not improve. The patient was pronounced dead by doctors at 08:40 on 5 April 2020.

SARS-CoV-2 is a type of coronavirus that was first reported to have caused pneumonia-like infection in humans on 3 December 2019. 5 As a group, coronaviruses are a common cause of upper and lower respiratory tract infections (especially in children) and have been researched extensively since they were first characterised in the 1960s. 6 To date, there are seven coronaviruses that are known to cause infection in humans, including SARS-CoV-1, the first known zoonotic coronavirus outbreak in November 2002. 7 Coronavirus infections pass through communities during the winter months, causing small outbreaks in local communities, that do not cause significant mortality or morbidity.

SARS-CoV-2 strain of coronavirus is classed as a zoonotic coronavirus, meaning the virus pathogen is transmitted from non-humans to cause disease in humans. However the rapid spread of SARS-CoV-2 indicates human to human transmission is present. From previous research on the transmission of coronaviruses and that of SARS-CoV-2 it can be inferred that SARS-CoV-2 spreads via respiratory droplets, either from direct inhalation, or indirectly touching surfaces with the virus and exposing the eyes, nose or mouth. 8 Common signs and symptoms of the COVID-19 infection identified in patients include high fevers, severe fatigue, dry cough, acute breathing difficulties, bilateral pneumonia on radiological imaging and lymphopaenia. 9 Most of these features were identified in this case study. The significance of COVID-19 is illustrated by the speed of its global spread and the potential to cause severe clinical presentations, which as of April 2020 can only be treated symptomatically. In Italy, as of mid-March 2020, it was reported that 12% of the entire COVID-19 positive population and 16% of all hospitalised patients had an admission to the intensive care unit. 10

The patient, in this case, illustrates the clinical relevance of understanding COVID-19, as he presented with an ischaemic stroke underlined by minimal respiratory symptoms, which progressed expeditiously, resulting in acute respiratory distress syndrome and subsequent death.

Our case is an example of a new and ever-evolving clinical correlation, between patients who present with a radiological confirmed ischaemic stroke and severe COVID-19 pneumonia. As of April 2020, no comprehensive data of the relationship between ischaemic stroke and COVID-19 has been published, however early retrospective case series from three hospitals in Wuhan, China have indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke. 11 These studies have not yet undergone peer review, but they tell us a great deal about the relationship between COVID-19 and ischaemic stroke, and have been used to influence the American Heart Associations ‘Temporary Emergency Guidance to US Stroke Centres During the COVID-19 Pandemic’. 12

The relationship between similar coronaviruses and other viruses, such as influenza in the development of ischaemic stroke has previously been researched and provide a basis for further investigation, into the prominence of COVID-19 and its relation to ischaemic stroke. 3 Studies of SARS-CoV-2 indicate its receptor-binding region for entry into the host cell is the same as ACE2, which is present on endothelial cells throughout the body. It may be the case that SARS-CoV-2 alters the conventional ability of ACE2 to protect endothelial function in blood vessels, promoting atherosclerotic plaque displacement by producing an inflammatory response, thus increasing the risk of ischaemic stroke development. 13

Other hypothesised reasons for stroke development in COVID-19 patients are the development of hypercoagulability, as a result of critical illness or new onset of arrhythmias, caused by severe infection. Some case studies in Wuhan described immense inflammatory responses to COVID-19, including elevated acute phase reactants, such as CRP and D-dimer. Raised D-dimers are a non-specific marker of a prothrombotic state and have been associated with greater morbidity and mortality relating to stroke and other neurological features. 14

Arrhythmias such as atrial fibrillation had been identified in 17% of 138 COVID-19 patients, in a study conducted in Wuhan, China. 15 In this report, the patient was known to have atrial fibrillation and was treated with rivaroxaban. The acute inflammatory state COVID-19 is known to produce had the potential to create a prothrombotic environment, culminating in an ischaemic stroke.

Some early case studies produced in Wuhan describe patients in the sixth decade of life that had not been previously noted to have antiphospholipid antibodies, contain the antibodies in blood results. They are antibodies signify antiphospholipid syndrome; a prothrombotic condition. 16 This raises the hypothesis concerning the ability of COVID-19 to evoke the creation of these antibodies and potentiate thrombotic events, such as ischaemic stroke.

No peer-reviewed studies on the effects of COVID-19 and mechanism of stroke are published as of April 2020; therefore, it is difficult to evidence a specific reason as to why COVID-19 patients are developing neurological signs. It is suspected that a mixture of the factors mentioned above influence the development of ischaemic stroke.

If we delve further into this patients’ comorbid state exclusive to COVID-19 infection, it can be argued that this patient was already at a relatively higher risk of stroke development compared with the general population. The fact this patient had previously had an ischaemic stroke illustrates a prior susceptibility. This patient had a known background of hypertension and atrial fibrillation, which as mentioned previously, can influence blood clot or plaque propagation in the development of an acute ischaemic event. 15 Although the patient was prescribed rivaroxaban as an anticoagulant, true consistent compliance to rivaroxaban or other medications such as amlodipine, clopidogrel, candesartan and atorvastatin cannot be confirmed; all of which can contribute to the reduction of influential factors in the development of ischaemic stroke. Furthermore, the fear of contracting COVID-19, in addition to his vague symptoms, unlike his prior ischaemic stroke, which demonstrated dense left-sided haemiparesis, led to a delay in presentation to hospital. This made treatment options like fibrinolysis unachievable, although it can be argued that if he was already infected with COVID-19, he would have still developed life-threatening COVID-19 pneumonia, regardless of whether he underwent fibrinolysis. It is therefore important to consider that if this patient did not contract COVID-19 pneumonia, he still had many risk factors that made him prone to ischaemic stroke formation. Thus, we must consider whether similar patients would suffer from ischaemic stroke, regardless of COVID-19 infection and whether COVID-19 impacts on the severity of the stroke as an entity.

Having said this, the management of these patients is dependent on the likelihood of a positive outcome from the COVID-19 infection. Establishing the ceiling of care is crucial, as it prevents incredibly unwell or unfit patients’ from going through futile treatments, ensuring respect and dignity in death, if this is the likely outcome. It also allows for the provision of limited or intensive resources, such as intensive care beds or endotracheal intubation during the COVID-19 pandemic, to those who are assessed by the multidisciplinary team to benefit the most from their use. The way to establish this ceiling of care is through an early multidisciplinary discussion. In this case, the patient did not convey his wishes regarding his care to the medical team or his family; therefore it was decided among intensive care specialists, respiratory physicians, stroke physicians and the patients’ relatives. The patient was discussed with the intensive care team, who decided that as the patient sustained two acute life-threatening illnesses simultaneously and had rapidly deteriorated, ward-based care with a view to palliate if the further deterioration was in the patients’ best interests. These decisions were not easy to make, especially as it was on the first day of presentation. This decision was made in the context of the patients’ comorbidities, including COPD, the patients’ age, and the availability of intensive care beds during the steep rise in intensive care admissions, in the midst of the COVID-19 pandemic ( figure 1 ). Furthermore, the patients’ rapid and permanent decline in GCS, entwined with the severe stroke on CT imaging of the brain made it more unlikely that significant and permanent recovery could be achieved from mechanical intubation, especially as the damage caused by the stroke could not be significantly reversed. As hospitals manage patients with COVID-19 in many parts of the world, there may be tension between the need to provide higher levels of care for an individual patient and the need to preserve finite resources to maximise the benefits for most patients. This patient presented during a steep rise in intensive care admissions, which may have influenced the early decision not to treat the patient in an intensive care setting. Retrospective studies from Wuhan investigating mortality in patients with multiple organ failure, in the setting of COVID-19, requiring intubation have demonstrated mortality can be up to 61.5%. 17 The mortality risk is even higher in those over 65 years of age with respiratory comorbidities, indicating why this patient was unlikely to survive an admission to the intensive care unit. 18

Regularly updating the patients’ family ensured cooperation, empathy and sympathy. The patients’ stroke was not seen as a priority given the severity of his COVID-19 pneumonia, therefore the least invasive, but most appropriate treatment was provided for his stroke. The British Association of Stroke Physicians advocate this approach and also request the notification to their organisation of COVID-19-related stroke cases, in the UK. 19

Learning points

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is one of seven known coronaviruses that commonly cause upper and lower respiratory tract infections. It is the cause of the 2019–2020 global coronavirus pandemic.

The significance of COVID-19 is illustrated by the rapid speed of its spread globally and the potential to cause severe clinical presentations, such as ischaemic stroke.

Early retrospective data has indicated that up to 36% of COVID-19 patients had neurological manifestations, including stroke.

Potential mechanisms behind stroke in COVID-19 patients include a plethora of hypercoagulability secondary to critical illness and systemic inflammation, the development of arrhythmia, alteration to the vascular endothelium resulting in atherosclerotic plaque displacement and dehydration.

It is vital that effective, open communication between the multidisciplinary team, patient and patients relatives is conducted early in order to firmly establish the most appropriate ceiling of care for the patient.

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• Wunderink RG
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• Wang X-G , et al
• Grasselli G ,
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• Wang M , et al
• American Stroke Assocation, 2020
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• Zhang Y-huan ,
• Dong X-F , et al
• Li X , et al
• Hu C , et al
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• Xu J , et al
• British Association of Stroke Physicians

Contributors SB was involved in the collecting of information for the case, the initial written draft of the case and researching existing data on acute stroke and COVID-19. He also edited drafts of the report. MH was involved in reviewing and editing drafts of the report and contributing new data. SP oversaw the conduction of the project and contributed addition research papers.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Next of kin consent obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

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Acute stroke (nursing).

Prasanna Tadi ; Forshing Lui ; Lori A. Budd .

Affiliations

Last Update: August 17, 2023 .

• Learning Outcome
• Recall the causes of stroke
• Describe the pathophysiology of stroke
• Summarize the signs and symptoms of stroke
• List the nursing needs of a patient with a stroke
• Introduction

A cerebrovascular accident, more commonly known as a “stroke,” is broadly classified as either ischemic or hemorrhagic. In either category, the result is a loss of blood flow, nutrients, and oxygen to a region of the brain, resulting in neuronal damage and subsequent neurological deficits. There are numerous causes of stroke, such as prolonged hypertension, arteriosclerosis, and emboli, that have formed as a result of atrial fibrillation or rheumatic fever (see images 2 and 3). In younger patients, the possible list of causes may be broadened to include clotting disorders and various forms of vasculitis. In children, sickle cell anemia is also a common cause of stroke. In the event of a possible stroke presentation, a precise history and physical must be performed alongside emergent neurological imaging before administering any form of treatment. With early, focused treatment based on the stroke etiology, rehabilitation programs, and long-term lifestyle changes, one can maximize their chances for a meaningful recovery. [1]

• Nursing Diagnosis
• In adequate cerebral perfusion
• Impaired ability to communicate
• Impairment in physical mobility
• Altered sensory perception
• Inability to perform daily living activities
• Impaired swallowing
• Ineffective coping

Many etiologies can lead to a stroke. One of the most common causes is plaque formation secondary to low-density lipoprotein cholesterol (LDL) buildup within the arteries. The most common risk factors include hypertension, diabetes mellitus, and smoking. Thrombi can also develop at the bifurcation sites of the internal carotid, middle cerebral arteries, and basilar arteries. Emboli that cause strokes are thrombi formed at a distant site and then lodged in an artery of the brain. Embolic strokes are commonly caused by emboli that originate from the heart, especially in patients with preexisting heart arrhythmias (atrial fibrillation), valvular disease, structural defects (atrial and ventricular septal defects), and rheumatic fever. Emboli usually lodge in areas of preexisting stenosis. [2]

Strokes that occur in small vessels are most commonly caused by chronic, uncontrolled hypertension and arteriosclerosis. These strokes occur in the basal ganglia, internal capsule, thalamus, and pons. Uncontrolled hypertension in these areas can also lead to small hemorrhages. [3]

About 20% of all strokes are classified as hemorrhagic, with the most common etiology being uncontrolled hypertension. Other causes of hemorrhagic strokes include cerebral amyloid angiopathy, a disease in which amyloid plaques deposit in small and medium vessels, which causes vessels to become rigid and more vulnerable to tears. Deposition can occur anywhere, but they occur most commonly on the surfaces of the frontal and parietal lobes. The structural integrity of vessels is another critical consideration in hemorrhagic stroke. Aneurysms, arteriovenous malformations, cavernous malformations, capillary telangiectasias, venous angiomas, and vasculitis have all been identified as common causes of hemorrhagic strokes. [4]

• Risk Factors

In the United States, stroke is the fifth most common cause of death, and 60% of strokes occur outside hospitals. [5] On average, every 40 seconds, a person suffers from a stroke, and every 4 minutes, one death is caused by a stroke. [5] Stroke is the leading cause of disability worldwide. [6]

Risk factors for stroke include:

• Advanced age
• Hypertension
• Physical inactivity
• Hyperlipidemia

A thorough history is a critical first step toward making a diagnosis. A stroke should be high on the differential for a patient presenting with sudden, focal neurological deficits and/or an altered level of consciousness. Based on clinical presentation alone, it is almost impossible to differentiate between a hemorrhagic and an ischemic stroke. Common signs and symptoms include hemiparesis, sensory deficits, diplopia, dysarthria, and facial droop. More posterior strokes present with a sudden onset of ataxia and vertigo. Symptoms commonly attributed to increased intracranial pressure, such as nausea, vomiting, headache, and blurred or double vision, may provide evidence supporting a hemorrhagic stroke. In addition to gathering information about the symptoms, one needs to establish the time of their onset to decide whether fibrinolytic therapy is an option once the diagnosis of ischemic stroke is confirmed. [7]

A neurological exam is performed to ascertain stroke location, establish baseline function upon hospital admission, rule out a transient ischemic attack (TIA) and other stroke mimickers, and deduce potential comorbidities. It is composed of testing cranial nerve function, the range of motion and muscle strength, sensory integrity, vibratory sense, cerebellar function, gait, language, mental status, and level of consciousness. Baseline function is determined via the National Institutes of Health Stroke Scale (NIHSS), which focuses on the level of consciousness, visual and motor function, sensation and neglect, cerebellar function, and language capabilities. [8]  A peripheral vasculature exam is also completed and includes palpation of the carotid, radial, femoral, and posterior tibial pulses. [9]

Common signs and symptoms of stroke include:

• Numbness or weakness of the face
• Change in mental status
• Trouble speaking or understanding speech
• Homonymous hemianopsia - loss of half of the visual field
• Loss of peripheral vision
• Hemiparesis or hemiplegia - Weakness or paralysis of the face, arm, and leg on the same side 
• Ataxia - unsteady gait and inability to keep feet together
• Dysarthria - difficulty in forming words
• Dysphagia - difficulty in swallowing
• Paresthesia - numbness and tingling of extremities 
• Expressive aphasia - unable to form understandable words 
• Receptive aphasia - unable to comprehend the spoken word 

Serum blood glucose level via bedside finger-stick testing should be the first test for patients with neurologic deficits. This is to help identify and correct hypoglycemia if it is present.

Emergent non-contrast computed tomography (CT) of the head is one of the first diagnostic tests obtained in patients suspected of having a stroke. This test will identify hemorrhagic stroke if it is present.

The non-contrast CT may not readily identify ischemic strokes. Patients will usually undergo further neurologic imaging immediately after obtaining a noncontact CT. This imaging may include specialized contrast CT imaging to evaluate brain perfusion and/or contrast-enhanced CT angiography of the head and neck to identify any blocked vessels. [10] [11] [12]  At some centers, magnetic resonance imaging (MRI) is utilized for this additional imaging because of its superior sensitivity in detecting ischemic lesions. 

Cardiac monitoring with bedside telemetry and electrocardiograms is obtained in all patients with stroke-like symptoms.

Additional testing will include serum troponin, complete blood count with differential, lipid profile, hemoglobin A1c (HbA1c), blood urine nitrogen (BUN), creatinine, albumin, and glomerular filtration rate (GFR). In younger patients presenting with stroke symptoms, other labs that might be ordered include a coagulation panel, rheumatoid factor (RF), anti-nuclear antibodies (ANA), and other markers for vasculitis. [13]

In some cases, an electroencephalogram (EEG) may be obtained to rule out a post-seizure state. [14]

• Medical Management

Ischemic Stroke

• Before any treatment can be administered, the patient must be assessed for a stable airway, breathing, and circulation.
• The exclusion criteria for this treatment are based on guidelines from the American Heart Association/American Stroke Association.
• This therapy aims to dissolve the clot and restore blood flow to the affected regions.
• Time management is of the utmost importance in patients with an ischemic stroke because the fibrinolytic/thrombolytic therapy must be administered within 3 to 4.5 hours after symptom onset to be effective.
• In recent years significant advancements have been made in acute stroke care with the emergence of mechanical thrombectomy to remove the occluding clot and reestablish blood flow to the brain. [15]
• Within 24 to 48 hours of symptoms onset, patients should be placed on oral anti-platelet therapy, typically 325 mg of aspirin.
• Blood pressure should be maintained at slightly elevated levels for the first few days after a stroke to counter vasoconstriction. Blood pressure should also be lowered gradually over the next few days to treat underlying hypertension.

Hemorrhagic Stroke

• Some patients will undergo catheter-directed intracranial intervention for the cause of a spontaneous hemorrhagic stroke
• Most patients with this type of stroke are managed with intervention to relieve intracranial pressure, such as ventricular drain placement and/or a craniotomy
• Patients who were previously on anticoagulation agents will need reversal agents and plasma product transfusions to reverse coagulopathy
• Blood pressure should be monitored frequently with a goal systolic pressure of 140 mmHg
• To avoid over or under-correction, systolic blood pressure is acceptable within the range of 130 to 150 mmHg in these patients
• Some patients will be on seizure medications prophylactically to prevent spontaneous epileptiform discharges
• Nursing Management
• Assess mental status and level of consciousness
• Observe for neurological deficits with frequent and serial neurological assessments
• Measure and monitor pupil size
• Assess breathing
• Monitor vital signs
• Assess higher functions like speech, memory, and cognition
• Provide a quiet environment with the head of the bed elevated
• Elevate bed rails to prevent falls
• Leave the nurse bell button at the side of the bed in case the patient needs to go to the bathroom
• Prevent constipation and straining with stool softeners
• Watch for seizures
• Observe for changes in mood
• Provide deep vein thrombosis (DVT) prophylaxis 
• When To Seek Help
• If a change in mental status or loss of consciousness occurs
• If a change in neurologic assessments is noted
• If the patient experiences difficulty breathing or shortness of breath
• If vital sign assessment reveals fever or a sudden change in heart rate and/or blood pressure
• If the patient is unable to void
• If the patient has any evidence of skin breakdown
• If the patient experiences a fall
• Outcome Identification
• Improved consciousness
• Alert with preserved motor and sensory function
• Can ambulate, speak and swallow
• No signs of any neurologic deficits
• Stable vital signs
• Neurologic assessments
• Vital signs
• Cardiac rhythm monitoring
• Ability to swallow
• Ability to void urine
• Muscle strength and mobility
• Mood and behavior
• Coordination of Care

During the time-dependent early stroke phase and rehabilitation, stroke care involves an interprofessional team to prevent the disease. [16]  Once the stroke diagnosis is made, the patient may need extensive physical rehabilitation, speech therapy, and/or a dietary consult. For those who recover function within three months, the prognosis is good, but for those with residual neurological deficits, the outcome is guarded. Nurses must coordinate care with these interprofessional team members to ensure functional assessments and speech/swallow assessments have been made for these patients with the implementation of recommended interventions. 

• Health Teaching and Health Promotion

Educate the patient and caregiver on the following:

• Eating healthy
• Do not lead a sedentary lifestyle
• Observe compliance with medications
• Follow up with a clinician
• Do not smoke
• Control blood pressure, blood glucose, and hyperlipidemia
• Participate in regular exercise
• Risk Management

Patients with a stroke can deteriorate rapidly. Others may aspirate, fall or develop seizures. Thus, the nurse should monitor the patient closely for any new neurological deficit and inform the clinician. The bed railings should be raised because there is a high risk of falls. The patient must be assisted to compensate for any functional impairments that may increase their risk of falls.

• Discharge Planning

According to the American Heart Association and American Stroke Association, the following points are an essential part of the discharge discussion:

• Education regarding the causes of stroke
• Education regarding modifiable risk factors for stroke 
• Education regarding blood pressure and glucose management
• Education regarding healthy dietary intake
• Education regarding the use of assistive devices, as advised by the therapy teams to prevent the risk of falls
• Emphasizing medication compliance 
• Emphasizing follow-up compliance
• Ensuring patients and caregivers understand the signs and symptoms of stroke to ensure timely evaluation in the event of a recurrent stroke
• Ensuring patients and caregivers understand potential complications of therapy, especially bleeding, if they are discharged on blood thinners [17]
• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Stroke, Posterior Cerebral Artery Contributed by Dr. Okkes KUYBU, M.D.

Disclosure: Prasanna Tadi declares no relevant financial relationships with ineligible companies.

Disclosure: Forshing Lui declares no relevant financial relationships with ineligible companies.

Disclosure: Lori Budd declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Tadi P, Lui F, Budd LA. Acute Stroke (Nursing) [Updated 2023 Aug 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Stroke Anticoagulation. [StatPearls. 2024] Stroke Anticoagulation. Abbas M, Malicke DT, Schramski JT. StatPearls. 2024 Jan
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Current Status of Outcomes Reported by Patients With Stroke and an Analysis of Influencing Factors: Cross-Sectional Questionnaire Study

Affiliations.

• 1 Nursing Department, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China.
• 2 Department of Medicine, Southeast University, Nanjing, China.
• PMID: 39186763
• DOI: 10.2196/58330

Background: Stroke is the leading cause of acquired disability and the second leading cause of death worldwide. Its rate of incidence, disability, mortality, and recurrence is high, and the patients experience various symptoms of discomfort, which not only affect their rehabilitation function but also reduce their ability to perform daily activities and their quality of life. Nowadays, with the improvement of China's medical standards, patients are increasingly attentive to their quality of life and health status. However, diagnostic techniques and effective treatments for patients with stroke are still limited but urgently required.

Objective: This study aimed to evaluate the quality of life during hospitalization using a stroke patient-reported outcomes (PROs) scale and additionally to recognize potential factors and risk indicators that may impact recurrent events, facilitating early intervention measures.

Methods: This is a registry-based, retrospective observational cross-sectional study on patients with stroke. A convenient sampling method was used to select various indicators of patients. The Stroke-PRO scale was then used to assess patients' conditions across physical, psychological, social, and therapeutic domains. Multiple linear regression analysis was applied to identify factors influencing stroke PROs, while correlation analysis was conducted to explore the relationship between these outcomes and blood lipid levels.

Results: The mean Stroke-PRO score in this study was 4.09 (SD 0.29) points. By multiple linear regression analysis, residence, occupation, physical exercise, Barthel index, Braden scale, National Institutes of Health Stroke Scale scores at admission, and stroke type were the risk factors for reported outcomes of patients with stroke (P<.05). Correlation analysis showed that serum triglyceride, total cholesterol, and low-density lipoprotein were negatively correlated with Stroke-PRO scores in patients with stroke (P<.05), while high-density lipoprotein was positively correlated with patients with stroke (P<.05). The 95% CI was -0.31 to -0.03 for triglyceride, 0.17-0.44 for high-density lipoprotein, -0.29 to -0.01 for cholesterol, -0.30 to -0.02 for low-density lipoprotein, and -0.12 to 0.16 for blood glucose.

Conclusions: Patients with stroke have a low level of health, and their reported outcomes need to be improved. Accordingly, nursing staff should pay attention to the quality of life and blood lipid indexes of patients with stroke, actively assess their actual health status, and take early intervention measures to promote their recovery.

Keywords: blood lipids; correlation analysis; influence factor; nursing care; patient-reported outcomes; stroke.

©Jia Sun, Liang Ma, Xiao Miao, Hui Sun, SuSu Zhu, Ran Zhang, LeLe Fan, TingTing Hu. Originally published in JMIR Formative Research (https://formative.jmir.org), 26.08.2024.

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Open Access

Peer-reviewed

Research Article

A qualitative study of stressors faced by older stroke patients in a convalescent rehabilitation hospital

Roles Formal analysis, Investigation, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliation Department of Occupational Therapy, Tokyo Bay Rehabilitation Hospital, Narashino, Chiba, Japan

Roles Writing – review & editing

Affiliation Department of Occupational Therapy, Teikyo Heisei University, Toshima, Tokyo, Japan

Affiliation Department of Occupational Therapy, Saitama Medical Center, Kawagoe, Saitama, Japan

Affiliation Faculty of Human Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan

• Yuta Asada, 
• Kaori Nishio, 
• Kohei Iitsuka, 

• Published: August 26, 2024
• https://doi.org/10.1371/journal.pone.0309457
• Peer Review
• Reader Comments

This study aimed to explore the stressors experienced by older patients with stroke in convalescent rehabilitation wards in Japan. Semi-structured interviews were conducted with four stroke patients aged > 65 years who experienced a stroke for the first time in their lives. The interviews were analyzed using the Steps for Coding and Theorization method for qualitative data analysis. The results of the qualitative analysis demonstrated that patients experienced specific stressors, such as, difficulty in movement of the paralyzed hand, fear of stroke recurrence, and dietary problems. Some stressors were manageable through healthcare professionals’ active and sensitive communication strategies. These stressors were derived from the theoretical framework of “stressors related to hospitalization” and “stressors related to the illness”. Additional stressors emerged from the interaction between these two types within the theoretical framework. The results of this study contribute to a deeper understanding of the specific stressors experienced by older stroke patients during the recovery process.

Citation: Asada Y, Nishio K, Iitsuka K, Yaeda J (2024) A qualitative study of stressors faced by older stroke patients in a convalescent rehabilitation hospital. PLoS ONE 19(8): e0309457. https://doi.org/10.1371/journal.pone.0309457

Editor: Chinh Quoc Luong, Bach Mai Hospital, VIET NAM

Received: February 24, 2024; Accepted: August 13, 2024; Published: August 26, 2024

Copyright: © 2024 Asada et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Stress is a nonspecific response of the body to external stimuli [ 1 ]. Stress varies as the stressors faced by individuals differ depending on their age, sex, and social role [ 2 ]. Stressors include physical, biological, chemical, psychological, and social factors. The accumulation of these stressors causes stress, which, if not adequately addressed, can lead to physical or mental health problems, such as cardiovascular disease and depression, respectively [ 3 ]. To prevent these stress-related diseases, it is imperative to identify and address the stressors.

Patients often face various stressors in inpatient settings as their physical and human environments differ significantly from those of their regular home settings [ 4 ]. As the length of the hospital stay increases, patients may become particularly vulnerable to stressors such as “concern for family” and “anxiety about financial situation” [ 4 ]. The severity of a stroke, the age of the patient, and the presence of underlying medical conditions are factors that tend to extend the duration of hospitalization [ 5 ]. The incidence of stroke increases with age and is more common among older adults [ 6 ]. Moreover, patients present with a variety of symptoms, such as motor paralysis and higher brain dysfunction, and their ability to perform activities of daily living (ADL) becomes more limited. In particular, convalescent rehabilitation hospitals have a prolonged hospital stay [ 7 ] as one of their goals is to help patients return to the community and their homes.

Much of what is known about stressors related to stroke involves the risk of stroke onset [ 8 , 9 ], and there are insufficient studies on the stressors faced by older stroke patients in hospitals. Clarifying these unspoken stressors can contribute to reducing the stress of hospitalization for older stroke patients during convalescent rehabilitation, meeting their true needs, and enriching their lives after discharge. Few studies have elicited patients’ true feelings regarding stressors in convalescent rehabilitation wards. The purpose of this study is to provide a deeper understanding of the specific stressors experienced by older stroke patients in convalescent rehabilitation wards during their hospital stay.

Materials and methods

We conducted a qualitative study and interviewed each participant separately. The interview transcripts were analyzed according to the “Steps for Coding and Theorization” method (SCAT), a sequential and thematic qualitative data analysis technique [ 10 – 12 ].

This study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ), a checklist designed to improve the transparency and reliability of qualitative research [ 13 ] (S1 Table in S1 File ).

Preparation for the study

The first author (hereafter, “the author”) is a M.S. student in comprehensive human sciences and male occupational therapist with six years of clinical experience in recovery rehabilitation. Before this study was conducted, the author reviewed the literature on SCAT, conducted an analysis, and attended a workshop for SCAT developers to deepen his understanding of the analysis methods to ensure the accuracy of the analysis [ 10 – 12 ].

Participants

Patients aged 65 years or older, experiencing stroke for the first time, and hospitalized in a recovery center were included in the study. Patients who had difficulty answering the interview questions owing to the effects of aphasia, hospitalized patients in the charge of an interviewer, patients diagnosed with dementia or psychiatric disorders, and patients who were hospitalized for a short period of approximately one month were excluded.

Patients were asked to cooperate in the study and fully informed about the purpose and significance of the study, research methods, voluntary nature of research cooperation and freedom to withdraw, and handling of personal information. Signing a consent form indicated patients’ willingness to cooperate in the study.

Interview procedure

Three interviews were conducted between June and November, 2022. The interviewer asked questions according to an interview guide. Semi-structured in-person interviews were conducted in a private room in the hospital that the author is affiliated with, involving the patients and interviewer only. The first interview was conducted at the time of hospital admission, and subsequent interviews were conducted several times, with a gap of approximately one month. The interviews were recorded with the participants’ consent using the voice recorder function of an iPad and transcribed afterwards. The interview transcripts were not returned to participants for comments or correction. The interviewer recited the patients’ statements to them and made efforts to confirm the content of the statements to ensure data accuracy.

The interview guide was developed based on a preliminary survey of two stroke patients to determine ease of response. The content of the interview guide was first explained to the participants through specific examples to help them fully understand the difference between “stress” and “stressors.” The guide began by explaining, through specific examples, what the stressors in this study were. To investigate the stressors faced by older stroke patients in recovery, we asked, “What comes to mind when you hear the term ‘stressors in hospitalization’?”

Data analysis

We predicted that the outcome of the interviews would be strongly influenced by the participants’ individual characteristics. Therefore, to obtain objective results, we used the SCAT technique that specializes in coding and theorization and can be applied to a small amount of data. The SCAT method consists of the following steps [ 10 – 12 ]:

Step 1: Focus words from within the interview texts.

Step 2: Words outside the text that can replace the words from Step 1.

Step 3: Words that explain the words in Step 1 and Step 2.

Step 4: Themes and constructs, including the process of writing a story and offering theories that weave the themes and constructs together.

As this study was designed to create multiple storylines from a single participant, we integrated those multiple storylines into a single storyline and wrote a theoretical description, ensuring no loss of chronological contextuality and individuality of the storylines. The data analysis and confirmation process were conducted by the author and three other authors who were not involved in the interview process.

Ethical considerations

This study was approved by the Ethical Review Committee (Approval No. 289–2) of Tokyo Bay Rehabilitation Hospital.

Basic attributes of the participants

Five participants who met the inclusion criteria were recruited for the study. One participant (female) was excluded owing to early discharge from the hospital on short notice. Thus, four patients (two male and two female) were included in the study. The participants’ average age was 79.3 years (range: 71–88 years). Their disabilities included cerebral hemorrhage (one patient) and cerebral infarctions (three patients).

The average duration of the series of 12 interviews was 20.3 minutes, ranging from 7.5 to 32.7 minutes.

Storyline and theoretical descriptions

In the sections below, the storylines and theoretical descriptions as well as quotes from each participant, are described.

Case 1: Mr. A, facing an inconvenient situation.

At the time of the first interview, Mr. A experienced stress owing to an inconvenient situation during hospitalization. He was unable to perform the activities he did before the onset of the disease, especially owing to the psychological burden caused by the inability to eat and drink according to his preferences. He also expressed dissatisfaction with the current situation, limitations in leisure-time activities, inconvenience of activities, and a sense of shame caused by assistance with bathing. Limited leisure-time activities resulted from challenges in moving his paralyzed hands. He specifically encountered difficulties in willingly engaging them to act. Furthermore, he was separated from his family as a result of hospitalization. Thus, he faced restrictions in eating and drinking luxury foods, lack of freedom in daily life, and lack of family time.

“ Not being able to do things freely is the biggest stressor. All in all, there’s nothing better than that. I can’t eat what I like, or drink a lot. Even if I have a computer, I can’t use my right hand. I can’t even do my own hobbies. And, it is still significant whether or not you have a wife nearby.”

At the time of the second interview, Mr. A experienced stress regarding eating and drinking, including dissatisfaction with the variety of meals compared to before the disease onset, and the psychological burden owing to meals not being replaced on a daily basis. This was also the minimum element that Mr. A looked for during hospitalization. Other stress factors included a feeling of disappointment owing to limited leisure-time activities, and feelings of activity limitation and resignation owing to the inability to walk independently.

“ The most important thing is the food. Anyway, there’s nothing to do, so at least a meal, you’d think, wouldn’t you? The food is different from when we’re at home. It doesn’t help that I can’t walk. And, I think it’s a bit hard not to have hobbies.”

At the time of the third interview, Mr. A expressed that his biggest stress factor was difficulty moving his paralyzed dominant hand. This significantly impacted his daily self-care, including toileting and grooming. He also encountered limitations in various leisure activities, such as reading books. Eating and drinking induced a significant psychological burden. He felt dissatisfied with the lack of variety in meals as he could not manage to eat as well as previously.

“ Whatever I do, my hands don’t work. For example, when you brush your teeth. It’s the same when you go to the toilet and wipe your bottom. I can’t use my right hand. Also, I like books and I want to read, but I can’t turn the pages. And, unlike in the past, I eat rice and side dishes every day. My eating habits have changed drastically.”

Case 2: Ms. B, facing stressors caused by communal living.

At the time of the first interview, Ms. B faced stressors related to basic lifestyle habits, such as falling asleep and toileting, in the hospital. Variations in individual lifestyles and environmental factors, like noise and room brightness, contributed to sleep deprivation in shared living arrangements. Furthermore, inadequate management of the paralyzed side during sleep led to anxiety and sleep deprivation. Problems related to toileting needs arose owing to overlap in toilet timings with roommates and assisted by staff of the opposite sex.

“ I sometimes have trouble sleeping well at night because of noises or brightness. Everyone is trying to go to the toilet before rehabilitation, so the timing is… And with male nurses, there was a bit of resistance to using the toilet. After all, in shared living arrangements, everyone has a different rhythm of life.”

During the second interview, Ms. B continued to face stress owing to communal living. Stressors included abnormal breathing noises caused by roommates when falling asleep, noise problems during roommates’ movements, and nocturnal awakenings caused by physical environmental factors such as differences in depth of sleep. Additionally, there were case of sleep problems caused by the staff’s response to a roommate’s problematic behavior, and case of nocturnal awakenings caused by noise from staff responses. Other issues included self-perceived persistent distress over defecation problems and dealing with defecation needs in a time-constrained environment, with a roommate.

“ Like last time, in shared living arrangements, everyone has a different rhythm of life, but it can’t be helped. Sleep, you know, because some people go to the toilet at night or early in the morning, so it’s quite noisy and you can’t sleep well. And the nurse puts the patient next to me to sleep, and there are all sorts of noises when she does that. We all have the same desire to go to the toilet before rehabilitation, so we don’t make it in time. Toilets are a perpetual problem.”

At the time of the third interview, Ms. B had problems with how he interacted with his roommates and stressors related to falling asleep at night. Ms. B was dissatisfied with differences in personal characteristics in communal living, and concerned about the deterioration of his relationship with his roommates over defecation. Furthermore, stress was caused by differences in lifestyle in communal living affecting sleep and awakening during the night owing to physical environmental factors such as noises made by roommates. Sudden changes in training hours also caused dissatisfaction.

“ Like how to communicate with people in the room. Like sleeping. Because of the lights and noise when my roommate goes to the toilet at night. Roommates have different living patterns. In rehabilitation, though, there were some questionable things like time changes.”

Case 3: Ms. C, facing an excrement problem and anxiety about stroke recurrence.

At the time of the first interview, Ms. C faced the problem of excrement in communal living. Dissatisfaction was caused by the suppression of excretory behavior and rejection of excretion in communal living, leading to anxiety. There were also conflicts and a psychological burden caused by the staff’s lack of information sharing, which led to restraining from defecating after unpleasant experiences.

“ I don’t like the situation of one toilet for four people. I and others are suffering. I thought it was hard. I didn’t know that you have to press the nurse call. Then I wished they had told me from the beginning. That was a bit of a shock.”

At the time of the second interview, Ms. C expressed dissatisfaction with their lack of independence in elimination. This led to a sense of aversion caused by dealing with the need to defecate frequently during the night and self-consciousness about requests for nighttime defecation assistance, which, in turn, led to resisting the need to defecate, a distressing experience unique to the patient.

“ I feel bad because I have to go to the toilet in the middle of the night. But I try to be patient. If it was during the day, I would ask the nurse to help me, but at night I would still feel sorry. It’s painful. You have to be experienced to understand.”

At the time of the third interview, Ms. C was anxious about the gap between their life at home after discharge and their life in the hospital and about the gradual decline of their brain functions. They also experienced anxiety owing to the fear of stroke recurrence and an undecided medical support system for the prevention of recurrence. These stressors were related to worry caused by a lack of information sharing by the staff and delays in sharing information about discharge from the hospital.

“ I have a little bit of anxiety about my future and my life. Because I’ve got comfortable here. And I don’t know what I would do if I fell ill again. No one is going to talk to me about it. I’m a bit worried about that. That’s what I’m most worried about.”

Case 4: Mr. D, facing a meal problem.

At the time of the first interview, Mr. D expressed their stress that they had to hold their toileting until the hospital staff arrived when they needed to defecate. This occurred as the hospital staff were extremely busy, and they experienced failure in excretory management. However, at the time of the interview, they were able to use the toilet independently.

“ I’ve had a leak before the nurse came. She can’t come right away, she’s too busy. It’s gone now.”

At the time of the second interview, Mr. D had a low appetite owing to low-temperature meals and refused to eat as a result of inappropriate meal temperature. Additionally, there were difficulties with grooming movements around the use of the wash basin and dealing with the need to defecate in communal living.

“ The rice and side dishes are cold. So I feel sorry to leave it. I can eat it beautifully when it’s warm. But when it’s cold, I just can’t. After the meal, I can’t wash my hands because some people wash their hands in their rooms first. When I want to go into the toilet, there are people ahead of me. It can’t be helped.”

In the third interview, Mr. D felt stress when the meal was not hot enough to eat and lost their appetite. He also felt stress when his mealtime was delayed as it that cause would take time for them to do their personal grooming after returning to their room where their roommate occupied t the wash basin.

“ Side dish is cold. Wish it was room temperature. I eat my meals late, so I’m the last one to go back to my room. So, I can’t wash my hands first.”

In this study, semi-structured interviews were conducted to identify the stressors faced by older patients with stroke during convalescent rehabilitation, throughout hospitalization; data analysis was conducted using SCAT.

Based on the storylines and theoretical descriptions, the stressors experienced by stroke patients were categorized into “stressors related to hospitalization” and “stressors related to the illness” [ 4 ].

Stressors related to hospitalization

The results of this study revealed that older stroke patients in convalescent rehabilitation face stressors related to ADLs, such as eating, sleeping, grooming, and toileting; leisure activities; problems with roommates in communal living; and inability to be with their family members. In this study, the first interview was conducted at the time of admission, and stressors were reported by all participants. Stress during hospitalization is caused by the fact that patients are forced to live a life with less freedom than before [ 4 ].

The psychological burden is particularly high for older adults as they have a reduced ability to adapt to changes in the external environment compared with younger patients [ 14 ]. In light of the above, older stroke patients may face a variety of stressors from the early stages of hospitalization compared with younger patients; therefore, intervention against these stressors is necessary from the early stages of hospitalization.

Factors such as relationships with roommates may lead patients to experience discomfort [ 15 ], and the way patients relate to their roommates is considered important. In this study, physical environmental factors caused by differences in lifestyle and the timing of toilet and wash basin use with roommates emerged as stressors. Additionally, these factors affected the participants’ ADL, such as grooming, toileting, and sleeping. Considering these findings, it is important for patients living together to consider each other’s needs. Therefore, it is necessary for patients to communicate with each other to deepen their understanding, and healthcare professionals are expected to play a role in building such relationships.

Furthermore, stressors such as meal variations and meal temperature emerged rather than stressors such as taste and preference. Older people tend to experience a decline in dietary variety owing to a decline in physical and oral functions and appetite [ 16 ]. Moreover, older patients undergoing treatment for cerebrovascular disease are more likely to experience changes in food preferences than younger patients [ 17 ], which is not consistent with the results of the present study. Given that the amount of food intake in a hospital setting is linked to the quality of food, including taste and the dining environment [ 18 , 19 ], there is a need for further research on qualitative aspects of meal preparation, such as food variations and appropriate temperatures. However, studies on meal variations and temperature are limited. In the future, these should be investigated in detail as characteristic stressors faced by older stroke patients during convalescent rehabilitation.

Stressors related to the disease

The results revealed that older stroke patients in rehabilitation face stressors such as difficulty moving the hand affected by motor paralysis, recurrent strokes, lack of information given by healthcare providers, and inappropriate actions or words of healthcare providers. Approximately 50% of stroke survivors experience unilateral motor paralysis [ 20 ]. Improvement in motor paralysis of the upper limbs and fingers contributes to greater independence in ADL [ 21 , 22 ]. It not only affects ADL but a wide range of activities, such as housework and leisure activities [ 23 , 24 ].

In this study, there were patients whose hobbies were limited by difficulty in moving the paralyzed hand. Additionally, based on the interviews at the time of admission, activity limitation caused by paralysis was a stressor faced from the time of admission itself. Therefore, early interventions and psychological support are needed for patients with paralysis.

A lack of information about the disease may also increase patient anxiety and cause dissatisfaction among healthcare providers [ 4 ]. Stroke recurs at a rate of 2.2% to25.4% within one year of disease onset, 12.9% within two years, and approximately 16% within five years [ 25 ]. Therefore, it is important to support stroke patients to prevent recurrence [ 26 ]. The participants were interviewed before discharge from the hospital about stressors such as recurrent stroke and lack of information provided by healthcare providers. This suggests that providing information to older patients with stroke undergoing convalescent rehabilitation to prevent recurrence is very important, especially for patients who are about to be discharged from the hospital, and that a lack of information can cause stress. Furthermore, communication between stroke patients and healthcare professionals does not always match [ 27 ]. Efforts should be made to prevent a lack of information, considering the patient’s cognitive function and the degree of higher brain dysfunction.

Additionally, stressors such as the personal care of patients by healthcare professionals of the opposite sex, and behaviors and words caused by misunderstandings on the part of healthcare professionals emerged. Patients may experience discomfort and high psychological distress owing to factors such as the attitudes and actions of healthcare workers [ 16 , 28 ]. An inadequate explanation or lack of consideration of shame may also arouse anger in patients [ 29 ]. Stroke patients are placed in a situation where they are prone to feelings of shame owing to assistance with ADL such as bathing and toileting. Therefore, healthcare professionals must be sensitive to patients when providing daily care. Stress can be prevented through appropriate attitude and information sharing.

Various symptoms, such as motor paralysis, sensory disturbance, higher brain dysfunction, and cognitive decline, appear as post-effects of stroke. The complex interplay between these symptoms causes a decline in the ability to perform ADL [ 30 – 32 ]. In this study, there were patients for whom difficulty in achieving independence in ADL was a stressor. Patients with higher levels of ADL independence had higher self-efficacy, and successful experiences were effective in forming self-efficacy [ 33 ]. This principle should be applicable to older stroke patients in convalescent rehabilitation hospitals. The positive outcomes of their hospital experience may be partially attributed to reduced stress.

Additionally, some patients faced limitations in self-care, stressors related to hospitalization owing to the aftereffects of stroke, and stressors related to illness. Given these findings, it was suggested that stroke patients may have been stressed by the interaction of “stressors related to the disease” and “stressors related to hospitalization.” However, if one of these stressors can be adequately addressed, it is likely that related stressors can be reduced.

Limitations

In conclusion, we clarified the stressors faced by older stroke patients in convalescent for rehabilitation. However, this study has some limitations. First, the study was severely limited by the small number of patients, which prevents us from drawing some important conclusions. The SCAT method can be used to analyze data from a small number of people because it provides a theoretical description from the participants’ storylines; however, the number of participants in this study was not sufficient to generalize the findings. Second, this study did not fully consider the participants’ individual characteristics, such as personality and background, nor did it analyze the patients in terms of their pathology and sequelae. Therefore, the results obtained should be interpreted carefully, as individual bias was not sufficiently eliminated. In future, it is necessary to select other participants and data analysis methods that consider participants’ individual characteristics and the aftereffects of stroke and recruit more participants to elucidate the stressors faced by older stroke patients in convalescent rehabilitation.

Stressors specific to older stroke patients were identified, including difficulty moving the paralyzed hand, recurrent stroke, and diet-related stressors. Stressors identified in this study can be broadly classified into “stressors related to hospitalization” and “stressors related to the disease,” consistent with previous studies [ 4 ]. However, it was found that stress is also caused by the interaction between “stressors related to hospitalization” and “stressors related to the disease.” To the best of our knowledge, thus far, no reports have identified the specific stressors faced by older stroke patients. Therefore, this study provides valuable information from a first-hand perspective that will lead to a deeper understanding of the specific stressors experienced by older stroke patients during recovery. Future studies should explore how various stressors lead to stress in older stroke patients at various types of rehabilitation hospitals.

Supporting information

S1 file. consolidated criteria for reporting qualitative studies (coreq): a 32-item checklist..

https://doi.org/10.1371/journal.pone.0309457.s001

Acknowledgments

We thank all the participants who agreed to be interviewed for this study. We also thank the members of the Rehabilitation Science Degree Program, Graduate School of Comprehensive Human Sciences, University of Tsukuba, for their guidance and encouragement during this study.

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Nursing care for stroke patients: current practice and future needs.

1. Introduction

2. materials and methods, 2.1. research design, 2.2. setting and sample, 2.3. recruitment and data collection, 2.4. data analysis, 3.1. sociodemographic characteristics, 3.2. survey of nursing practices for stroke patients, 3.3. nursing practices for stroke patients across units, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, public involvement statement, guidelines and standards statement, acknowledgments, conflicts of interest.

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Share and Cite

Babkair, L.A.; Safhi, R.A.; Balshram, R.; Safhei, R.; Almahamdy, A.; Hakami, F.H.; Alsaleh, A.M. Nursing Care for Stroke Patients: Current Practice and Future Needs. Nurs. Rep. 2023 , 13 , 1236-1250. https://doi.org/10.3390/nursrep13030106

Babkair LA, Safhi RA, Balshram R, Safhei R, Almahamdy A, Hakami FH, Alsaleh AM. Nursing Care for Stroke Patients: Current Practice and Future Needs. Nursing Reports . 2023; 13(3):1236-1250. https://doi.org/10.3390/nursrep13030106

Babkair, Lisa A., Razan A. Safhi, Raghad Balshram, Rahaf Safhei, Atheer Almahamdy, Fatimah Hamad Hakami, and Ali Matouq Alsaleh. 2023. "Nursing Care for Stroke Patients: Current Practice and Future Needs" Nursing Reports 13, no. 3: 1236-1250. https://doi.org/10.3390/nursrep13030106

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• Published: 26 August 2024

Caregiver burden after stroke: a 10-year follow-up study of Polish caregivers for stroke patients

• Krystyna Jaracz 1   na1 ,
• Barbara Grabowska-Fudala 1   na1 ,
• Jan Jaracz 2 ,
• Jerzy Moczko 3 ,
• Paweł Kleka 4 ,
• Aleksandra Pawlicka 5 &
• Krystyna Górna 6  

BMC Nursing volume  23 , Article number:  589 ( 2024 ) Cite this article

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Metrics details

A long-term assessment of stroke outcomes from the perspectives of patients and their caregivers is important for optimising long-term post-stroke care. The extended effects of stroke caregiving, particularly caregiver burden beyond 5 years since stroke, remain to be determined. Hence, this study aimed to determine caregiver burden at 10 years after stroke, compare the burden severity at 10 years with its levels at 5 years and 6 months after stroke, and identify predictors of the burden severity at 10 years post-stroke.

A longitudinal follow-up study including a group of first-ever stroke patients/informal continuous caregivers pairs was followed for 10 years and interviewed face-to face at their home setting.

Caregiver burden was evaluated with the Caregiver Burden Scale. Potential predictors were examined using standardised measures and identified by applying the Classification and Regression Tree.

A total of 40 caregiver/patient pairs participated in the study. At 10 years, 47.5% of the caregivers experienced a considerable burden. This was more than after 5 years (17.5%) and comparable to that after 6 months (37.5%), p  < 0.003. Longer time spent caregiving, caregivers’ weaker sense of coherence, more severe stroke, and caregivers’ anxiety were the independent predictors of considerable burden 10 years after stroke.

Conclusions

Caregivers’ burden in the late chronic post-stroke phase is a significant problem, as nearly half of the caregivers experience a substantial burden. This problem mainly concerns individuals who spend at least 7 h daily caregiving and have a lower Sense of Coherence.

The long-term evaluation of stroke consequences reported by stroke patients and their caregivers can be an important source of information for healthcare professionals in order to optimise the care and support they provide at various stages of life after stroke.

Peer Review reports

Introduction

Stroke is a disease characterised by a sudden onset and can have serious short and long-term consequences for both individual patients and societies [ 1 ]. It ranks as a leading cause of disability-adjusted life years lost worldwide [ 2 ]. Over the past 20 years, there has been significant progress in stroke management increasing the chance of survival and recovery during the acute and early post-stroke phases [ 3 , 4 ]. However, the longer-term effects remain a significant concern [ 5 ]. Research showed that 5 to 6 years after stroke, approximately 50% of patients die, 25% have a recurrent stroke, and about 20 to 45% are functionally dependent [ 6 , 7 , 8 , 9 , 10 , 11 ]. At ten years, these figures are as follows: 70%, 40—50%, and 29—50%, respectively [ 7 , 11 , 12 , 13 ].

The consequences of stroke affect not only patients but also their loved ones, usually family members, who take over the care responsibilities after the hospital discharge [ 14 ]. Family caregivers, and more broadly, informal caregivers, play a crucial role in poststroke recovery, providing patients with practical, emotional and spiritual support [ 15 ]. They begin to fulfil their caregiving role immediately upon the patient’s return from the hospital and continue it for several months or years, going through various stages, during which they might encounter significant difficulties and challenges, specific to each stage [ 16 ].

Regardless of the time elapsed since the stroke and the duration of caregiving, if the challenges are big and the caregivers’ resources are limited along with insufficient external support, a substantial burden arises [ 17 , 18 ]. This is broadly defined as “the extent to which caregivers perceived their emotional, physical health, social life, and financial status as a result of caring for their relative” [ 19 ] (p. 261).

Many studies investigated the burden among stroke caregivers during the last two decades, but only a dozen of them examined it longitudinally [ 16 , 20 , 21 , 22 ]. These studies showed that 22.7% to 59% of caregivers experienced an elevated burden during the first 6 months after hospital admission, hospital discharge, or admission to rehabilitation [ 20 , 21 , 22 ], 20.8% to 52% after 1 year [ 20 , 21 ], 43% at 3 years, and 30% at 5 years [ 21 , 23 ] which indicates that caregivers gradually adapt to changes caused by their loved one’s illness.

However, what happens in a more distant period, when caregivers age, some patients experience a recurrent stroke or late stroke-related and health-related changes and their functional status deteriorates? [ 13 , 24 , 25 ]. The literature does not answer this question as, to the authors’ best knowledge, there are no longitudinal studies beyond the 5 years. Hence, they decided to continue their previously conducted research [ 23 , 26 ] to determine and further understand the long-term consequences of stroke in terms of burden, its evolution, and determinants. By doing this, the study fits into one of the key targets specified in the Action Plan for Stroke in Europe 2018–2030 [ 27 ], pointing to the need for research based on patient and carer reports on life after stroke covering the entire lifespan in order to optimise a lifelong care following stroke.

The aims of this study therefore were: 1) to describe the caregiver burden at 10 years after stroke, 2) to compare the burden severity at 10 years with its levels at 5 years and 6 months after the event, and 3) to identify patient and caregiver characteristics determining the burden severity at 10 years post-stroke.

Participants and methods

A longitudinal prospective follow-up design was adopted in the study. The study was conducted in the city of Poznań and its surrounding areas, within approximately 100 km from Poznań, in the Great Poland Voivodeship (a voivodeship being the highest-level administrative division of Poland). Poznań is located in the central-western part of Poland, in the central area of the voivodeship and has a population of over 500.000.

Participants

A group of caregivers of stroke patients consecutively hospitalised in the stroke subunit of the neurological department at the Voivodeship Hospital (formerly the Voivodeship Integrated Hospital) in Poznań due to their first-ever stroke between 2005 and 2008 were enrolled. The patients were assessed at discharge, and subsequently, the patient/caregiver pairs were examined 6 months later (Time 1, T1), then 5 years after T1 (Time 2, T2), and again after an additional 5 years (Time 3, T3), resulting in a total observation period of over 10 years. Results of the T1 and T2 assessments have been published earlier [ 23 , 26 ].

The current assessment focuses on the 10-year outcome of continuous caregiving and possible changes in the burden severity seen from a more distant perspective. Details about the sampling, the initial sample, and data collection procedures were presented elsewhere [ 23 , 26 ]. In brief, the inclusion criteria for the patients comprised a first-ever stroke diagnosis, functional deficits at discharge, no other disabling or psychiatric conditions, pre-stroke independence in activities of daily living, and returning home after discharge. For the caregivers, they were as follows: being the primary caregiver, not receiving payment for caregiving, and not simultaneously providing long-term care for another individual at home.

Initially, during the patient’s hospitalisation, 223 patient/caregiver pairs were enrolled in the study. Between discharge and T1, 73 pairs were withdrawn due to patient deaths ( n  = 34), relocation to a care facility ( n  = 4), staying in a rehabilitation or other hospital ( n  = 5), inability to locate or failure to contact ( n  = 14), and refusal to participate ( n  = 16). Consequently, at T1, a group of 150 pairs took part in the study, and 88 at T2 (62 pairs were withdrawn since T1). Altogether, between T1 and T3, 110 participants dropped out, the reason being: a patient’s death ( n  = 35), transfer to a care facility ( n  = 2), a caregiver’s death ( n  = 1), discontinuation of caregiving ( n  = 6), refusal to participate ( n  = 4), and an inability to locate ( n  = 62). As a result, the final group consisted of 40 stroke patients and 40 caregivers. Before the T3 investigation, as before the previous ones, the participants were contacted personally by telephone, post, or mail. Those reached were asked whether they would be willing to participate in the follow-up study, and in case of agreement, the caregiver/patient pair was visited and interviewed in their homes by the same researchers as in T1 and T2.

Research measures

The same measures were used as in T1 and T2 [ 23 , 26 ]; therefore, they are only characterised in brief.

Caregiver measures

The 22-item Caregiver Burden Scale (CBS) [ 28 , 29 ] was used to assess the burden. The scale consists of 5 subscales, each scored from 1 to 4, with the total score ranging from 1 to 4, where a score of 2 or more denotes considerable burden. The total scale and subscale scores are counted as the mean values of the items included in the respective subscales and the entire scale. The 14-item Hospital Anxiety and Depression Scale (HADS, scored 0—21) [ 30 ] was applied to measure anxiety (HADS – A) and depression (HADS – D). The 8-item Berlin Perceived Social Support Scale (PSSS, scored 8 – 32) [ 31 ] was employed to measure social support. The 13-item Antonovsky Sense of Coherence Scale (SOC, scored 13—91) [ 32 ] was utilised to assess the caregivers’ inner resources for dealing with stressful life events. A single item (scored 1–5) from the WHOQoL-Bref [ 33 ] was used to evaluate overall satisfaction with health.

Patient measures

The Scandinavian Stroke Scale (SSS, scored 0—58) [ 34 ] and the Barthel ADL Index (BI, scored 0–20) [ 35 ] were applied to assess stroke severity and functional limitations.

The participants’ sociodemographic data and the patients’ clinical information were gathered from the medical records and with the help of a semi-structured questionnaire.

Statistical analysis

Descriptive statistics of the continuous variables were displayed as means, ± standard deviations (SD), min.- max., ranges, and categorical data were presented as numbers and percentages. Changes in the CBS scores and caregiver/patient characteristics between T1 and T3 were examined using the Cochrane Q test [ 36 ] and Friedman test [ 37 ] in conjunction with the Dunn and Conover-Iman post-hoc tests, respectively when the omnibus tests showed significant results. Supplementary to these analyses, a latent class analysis (LCA) [ 38 ] using observed polynomial measurement items was employed to identify a categorical latent variable, i.e. possible patterns of the caregiver burden change between T1 and T3 represented by mutually exclusive and internally homogeneous latent classes with the most likely members assigned to each class [ 38 ].

Associations between the caregiver burden and caregiver/patient characteristics at T3 were examined by the chi-square test, the exact Fisher test, the Student t-test, and the Mann–Whitney U test, depending on the type of variables and their distribution [ 39 ]. Possible predictors of burden severity at T3 were identified using the Classification and Regression Tree (CART) data mining method [ 40 ]. Based on multiple recursive algorithms, this method enables the prediction of a dependent variable (here, CBS: considerable and low) by determining the influence of independent variables. The significance level was established at p  ≤ 0.05, and all tests were two-tailed. Data were analysed with the Statistica 13 Package (TIBSCO Software Inc. 2017) and the R Package lcmm [ 41 ].

Ethical considerations

The study was approved by the Bioethics Committee at the University of Medical Sciences in Poznań (no.1365/05; 32/10; 283/12). All candidates for the study were informed about the study, and those who agreed to participate gave their informed written consent. The study was carried out in accordance with the principles of the Helsinki Declaration.

Characteristics of participants

As mentioned above, a total of 40 caregiver/patient pairs participated in all three follow-up assessments. The caregiver group consisted of 32 (80%) women and 8 (20%) men, with a mean age of 62.75 (SD = 11.24; range 39 – 83), mostly aged 60 or older ( n  = 28, 70%), the patients’ spouses ( n  = 28, 70%), living in the same house ( n  = 38, 95%). Most were retired or on disability pension ( n  = 27, 67.5%), 7 (17.5%) were professionally active, and the remaining had other sources of income. The patient group comprised 17 (42.5%) women and 23 (57.5%) men with a mean age of 66.90 (SD = 10.71 years; range 39—91), also in the majority over 60 years old ( n  = 33, 82.5%). According to the inclusion criteria, all the patients demonstrated a functional deficit at discharge (mean BI = 4.7; SD = 4.5). Nine patients (22.5%) had recurrent strokes between T1 and T2.

There were no significant differences between the T3 participants and those who dropped out between T1 and T3 regarding the caregiver’s gender ( p  = 0.603), age ( p  = 0.688), caregiver/patient spousal relationships ( p  = 0.073), living arrangement at T1 ( p  = 0.631) and patients’ SSS ( p  = 0.781) and BI ( p  = 0.748) at discharge and T1. The only difference was the patients’ age; those who dropped out were significantly older (66.45 years, SD = 12.45 vs 57.18 years, SD = 10.66; U  = 1249, p  < 0.001).

Caregiver burden, caregiver/patient characteristics at T3 and their changes between T1 and T3

At T3, the proportion of the caregivers experiencing considerable burden was significantly greater than at T2 (the post-hoc Dunn test with Bonferroni adjusted p  = 0.006) and comparable to that at T1. The average scores for the CBS total and its two subscales (General strain and Disappointment) followed a similar pattern. Also, the mean time spent caring per day at T3 was longer than at T2 and comparable to that at T1. The rest of caregiver/patient characteristics did not change significantly over time (Table  1 ). However, with respect to functional status, a detailed analysis of individual BI items at T2 and T3 revealed that at T3, the number of patients requiring assistance increased in 7 out of 10 activities. For instance, there was an increase in dressing by 7 individuals, in stairs use and bathing—by 6 individuals in each, and in toilet use and feeding—by 5.

In addition to the above results, Fig.  1 shows possible patterns of the burden severity over time according to the CBS total score revealed by the LCA. As can be seen, three trajectories (classes) were identified: 1) high, low and high (red line, n  = 5, 12.5%), 2) constantly low (CBS < 2; green line, n  = 17, 42.5%), and 3) constantly high (CBS ≥ 2, blue line, n  = 18, 45%). There were no significant differences in terms of caregivers’ self-rated health, HADS-A score, SOC, social support as well as caregivers’ and patients’ gender, age, and caregiver-patient relationships.

Trajectories of the caregiver burden level as a function of time. Legend: The thick coloured lines with grey shading show the extrapolated profiles of caregiver burden over time by distinguished class. The thin lines represent the actual profiles of individual subjects. Abbreviations: CBS, Caregiver Burden Scale

However, there were significant differences between these three classes regarding time spent caregiving: Class 1: mean (SD) = 10.0 h (9.6) vs Class 2: 2.1 (2.6) vs Class 3: 8.9 (7.7); HADS-D: Class 1: mean (SD) = 7.2 (2.9) vs Class 2: 4.4 (2.4) vs Class 3: 7.6 (3,9); SSS score: Class 1: mean (SD) = 48.2 (4.1) vs Class 2: 53.3 (5.0) vs Class 3: 40.8 (10,9); and BI: Class 1: mean (SD) = 14.8 (3.8) vs Class 2: 18.6 (2.0) vs Class 3: 12.7 (6.4).

The Classes 1 and 3 were characterised by a significantly ( p  < 0.05) longer time spent caring per day, more pronounced caregiver depressive symptoms (HADS-D), stroke symptoms (SSS) and functional deficit (BI) among the patients than the Class 2.

This 3-class model fitted the data best when compared to the 1 and 2-class models: AIC = 253.62 (1 Class) vs 169.15 (2 Classes) and 156.04 (3 Classes); BIC = 256.99 (1 Class) vs 191.10 (2 Classes) and 184.76 and (3 Classes).

Associations and predictors of considerable burden at 10 years after stroke

Among the caregiver/patient characteristics, six were significantly related to the burden severity at T3 in bivariate analysis (Table  2 ).

Four of them were identified as predictors of the considerable burden in the CART analysis: longer time spent caregiving (≥ 7 h: considerable burden, n  = 11 vs low, n  = 1; node 3), lower SOC (≤ 53: considerable burden, n  = 5 vs low, n  = 1; node 4), more severe stroke impairment (SSS ≤ 42: considerable burden, n  = 2 vs low, n  = 0, node 6) and anxiety symptoms (HADS – A ≥ 14.5: considerable burden, n  = 1 vs low, n  = 0, node 9) (Fig.  2 ). With these variables, 19 out of 21 caregivers were correctly predicted by the CART model as those with considerable burden. The classification accuracy was 95%.

The classification tree diagram showing predictors of considerable burden at T3. Abbreviations: HADS, Hospital Depression and Anxiety Scale; SOC, Sense of Coherence Scale; SSS, Scandinavian Stroke Scale; n, number

The first specific aim of the present study was to evaluate the severity of caregiver burden after 10 years of continued caregiving. The findings indicate that nearly half of the caregivers experienced significant burden, predominantly related to general strain and disappointment, as these domains of the Caregiver Burden Scale (CBS) scored highest. This suggests that feelings of fatigue, overwhelmed by duties and caregiving responsibilities, combined with a sense of being trapped, are significant issues for a considerable proportion of individuals providing care for stroke patients. Due to the lack of similar studies in the available literature with such a prolonged follow-up period, to our knowledge, the results cannot be directly compared with those of other authors. Nevertheless, support for the above explanation can be found in the observations of Watanabe et al. [ 42 ], Lee et al. [ 43 ] and other authors [ 44 ], who demonstrated that 67% of informal caregivers struggle with household tasks and work-related coping, 60% encounter difficulties in mental relaxation on average, 16 years post-stroke [ 42 ], and that 51.7% experience a high caregiver burden at 6 years [ 43 ]. These limited so far empirical data might indicate the necessity of paying greater attention to caregivers’ mental and physical condition during patients’ medical visits, although there is still a need for more prospective longitudinal research.

The second aim of the current study was to compare the burden severity at 10 years with its levels at 5 years and 6 months after stroke. The findings show that the percentage of individuals who demonstrated considerable burden at 10-year follow-up was higher than the burden level reported after 5 years, and comparable to that after 6 months. A similar temporal pattern was seen for the burden level according to the mean value of the CBS score. This may suggest that the intensity of the burden fluctuates over time, being at a high level in the first months, then gradually decreasing and perhaps stabilising at a relatively constant level for a few years, and afterwards rising again to a level close to that to the early phase of the caregiving journey. Considering the first 5 years of observation, e.g., T1 and T2 assessments, the current results confirm those obtained earlier in the group more than twice as large as the present one when more care recipients were still alive [ 23 ]. They are also in line with the findings of other authors [ 21 , 45 , 46 ] and remain in accordance with “the adaptation hypothesis” [ 47 ]. The subsequent rise of burden severity at T3, in turn, could have been related to the ageing effects of both patients and caregivers, of whom the vast majority were 60 years or older. They might have, therefore, experienced physiological changes and reductions in the functioning of several bodily systems, leading to a decline in overall functional performance [ 48 ]. In the case of patients, these ageing-associated changes are likely to be accelerated, as studies on the long-term consequences of stroke have shown [ 24 , 49 , 50 ] and, together with original post-stroke limitations, may pose a greater challenge for the caregivers. In the case of caregivers, in turn, the potential changes linked to ageing might have reduced the physical and psychological resources required for caregiving and, consequently, raised the experienced burden. This suggestion can be supported by the fact that time spent caregiving in the studied group significantly increased, while the SOC considered as “a life source of strength and resilience” [ 51 ] decreased compared to T2 and T1. The revealed increase in burden severity could have also been partially associated with the longer-term health effects of caregiving, as reported in previous studies [ 44 , 52 , 53 , 54 ] and detected in a supplementary analysis showing that the number of individuals reporting health problems between T1 and T3 increased from 55% to 72.5% (data not presented in the Results section).

Of the 5 CBS subscales assessed in the present work, “General strain” and “Disappointment” exhibited a similar patterns of change to the total score, providing additional support for the interpretation of the results presented above (see the first paragraph).

Although the average pattern of change in burden level from the perspective of 10 years post-stroke showed a growing trend after the period of decline, the time profile of burden was not the same for all participants, as three distinct trajectories have been identified, which confirms that informal caregiving for a stroke survivor is not “a homogenous experience”. This was previously indirectly demonstrated in shorter–term studies on quality of life after stroke, which additionally showed variation in the retrieved trajectories with respect to patient-related socio-demographic [ 55 , 56 ] and clinical factors [ 55 , 56 , 57 ]. In the present study, caregiver-level socio-demographic characteristics, such as, gender and age, did not significantly differentiate the trajectory classes. This could have been due to the relatively small diversity in the distribution of these variables, as the large majority of caregivers were women, aligning with the literature [ 58 ], and individuals over the age of 60. Nevertheless, it does not rule out the existence of such relationships since the available evidence regarding the effect of gender and age on care burden varies in studies [ 46 , 58 , 59 ], and this aspect undoubtedly deserves further, more analytical investigations.

In contrast to socio-demographic variables, clinical characteristics and length of time spent caregiving significantly differed across the trajectories. The “high – low – high” and “constantly high” trajectories included caregivers who spent more hours helping per day, whose loved ones had greater neurological and functional deficits, and those who demonstrated higher levels of depressive symptoms in comparison to the “constantly low” trajectory. The first three factors, especially hours of care per day and patient’s disability are frequently and consistently reported determinants or correlates of more significant burden in the longitudinal studies [ 21 , 58 , 60 , 61 , 62 , 63 ]. The same applies to depression [ 44 , 64 , 65 , 66 ], which, according to the meta-analytical review by Loh et al. [ 67 ], affects women more often than men, resulting in a greater burden in female caregivers, although reports on this topic are conflicting [ 21 , 46 , 68 ].

The third and final aim of this study was to identify patient and caregiver characteristics determining the burden severity at 10 years post-stroke. The results showed that several factors differentiated persons with low and considerable burden levels. Among them, longer daily care time, weaker SOC, greater neurological deficit, and a higher level of caregiver anxiety turned out to be the predictors of considerable burden in the CART analysis, with the first two seeming to be the more important considering the number of observations in the terminal nodes. All these factors are well-known in the subject literature and repeatedly identified by the authors. According to the recent meta-analysis by Zhu and Jiang [ 64 ], including studies with reported caregiving duration from 1 to 36 months, the strength of the relationships between these factors and caregiver burden expressed by effect size ranges from small for neurological function, through moderate for time spent caring, to large for SOC and caregiver anxiety. Based on the present and previous own research [ 23 ] as well as the literature [ 59 , 64 ], one can speculate that the set of predictors is relatively stable; however, their weight and position in the hierarchy may interchange depending on the phases of caregiving. Among the factors not associated with the caregiver burden, a recurrent stroke merits greater attention. The few reports on this subject suggest that caring for recurrent stroke patients may impose greater strain than caring for first-time stroke patients due to further functional deterioration and increased caregiver anxiety about future strokes [ 65 ]. Therefore, it is postulated that both patients and caregivers require closer post-discharge attention from health professionals [ 65 , 69 ]. However, the aspect of recurrent stroke needs to be verified in further studies.

Limitations and strengths

One limitation of the study is the substantial dropout rate (73.4%) among participants, potentially introducing bias and limiting the generalizability and statistical power of the findings. Nonetheless, the high attrition rate in stroke longitudinal research is a well-known phenomenon, given that the 10-year survival rate is approximately one-third [ 11 ]. Therefore, it may be understandable that the proportion of long-term caregivers is much smaller in the short-term. It should be noted, however, that the exact number of patients who died, despite all the authors’ efforts, could not be determined, as a significant portion of the participants could not be located. Another limitation is that only Polish caregivers participated in the study; therefore, the results likely do not reflect the cultural diversity of caregiving experiences, as well as the diversity arising from the differences in long-term care systems in different countries.

A positive aspect of the study is that it was conducted in the participants’ homes, with data collected face-to-face from the beginning by the same experienced researchers, which potentially enhances its reliability.

Conclusions and implications

Caregivers’ burden fluctuates over time and in the long-term chronic post-stroke phase poses a significant problem, as nearly half of the caregivers experience a substantial burden, which is more than in the mid-term chronic phase and comparable to that in the early phase. This problem mainly concerns individuals who spend at least 7 h a day caregiving and have weaker personal resources to cope with stress.

Since the caregiving strain extends far beyond the post-stroke adaptation phase more attention should be paid to the long–term caregivers. This is particularly important as stroke-related and caregiving-related health consequences may emerge or persist several years after the event [ 70 , 71 ]. Therefore, it would be advisable for health professionals, including nurses to identify the caregivers significantly burdened with caring responsibilities, especially since family caregivers are essential partners in the nursing care for individuals with chronic health conditions.

Based on the results, the authors suggest that possible interventions should be tailored to match the caregiving stage, and for those in the long-term stage, they might include respite care, enabling caregivers to have more time for themselves. Having more personal time gives a greater opportunity for maintaining social relationships, which in turn helps foster their Sense of Coherence [ 72 ], an important resource in coping with the challenges of caregiving for the next of kin who have had a stroke.

Availability of data and materials

The research data in the current study are available from the corresponding author upon reasonable request.

Abbreviations

Barthel Index

Classification and Regression Tree

Caregiver Burden Scale

Hospital Anxiety and Depression Scale

Latent class analysis

Perceived Social Support Scale

Standard deviation

Sense of Coherence

Scandinavian Stroke Scale

Time 1, Time 2, Time 3

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Acknowledgements

The authors are grateful to the patients and the caregivers for their participation in this long-term study, the time devoted, and the valuable information shared during this research.

A part of this study was supported by the Polish Ministry of Science and Higher Education (grant number N404 073 32/2200).

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Krystyna Jaracz and Barbara Grabowska-Fudala should be considered as the joint first authors. They made equal contributions to the manuscript.

Authors and Affiliations

Department of Neurological Nursing, Poznan University of Medical Sciences, 2 A, Rokietnicka Str, 60-806, Poznań, Poland

Krystyna Jaracz & Barbara Grabowska-Fudala

Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznań, Poland

Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznań, Poland

Jerzy Moczko

Faculty of Psychology and Cognitive Sciences, Adam Mickiewicz University, Poznań, Poland

Paweł Kleka

University of Warsaw, Warsaw, Poland

Aleksandra Pawlicka

Department of Psychiatric Nursing, Poznan University of Medical Sciences, Poznań, Poland

Krystyna Górna

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K.J. and  B. G-F.: conceptualisation and organisation of the study, methodology, funding acquisition, data collection, data analysis, writing the original draft and editing. J. J.: formal analysis, interpretation, critical revision. J.M.: statistical analysis, critical revision, figure preparation. P. K.:  statistical analysis, critical revision, figure preparation. A. P.: critical revision, language consultation and editing. K. G.:  conceptualisation, interpretation of data, critical revision. All authors reviewed and approved the manuscript for publication.

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Correspondence to Krystyna Jaracz or Barbara Grabowska-Fudala .

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Jaracz, K., Grabowska-Fudala, B., Jaracz, J. et al. Caregiver burden after stroke: a 10-year follow-up study of Polish caregivers for stroke patients. BMC Nurs 23 , 589 (2024). https://doi.org/10.1186/s12912-024-02251-x

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Received : 31 May 2024

Accepted : 09 August 2024

Published : 26 August 2024

DOI : https://doi.org/10.1186/s12912-024-02251-x

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Utilization of Artificial Intelligence to Improve Door-In Door-Out Times for Mechanical Thrombectomy-Eligible Patients at a Hub-and-Spoke Community-Based Comprehensive Stroke Center: A Single Case Study Presentation AI Improving DIDO Times

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Background:

Delays in the transfer of patients with hyperacute stroke may lead to treatment ineligibility due to the degree of cerebral hypoxic injury suffered. Cloud-based artificial intelligence applications may improve transfer times and expand access to advanced therapies. One case between a community-based comprehensive stroke center (CSC) and a primary stroke center (PSC) using a third-party telemedicine service and shared cloud-based artificial intelligence application may provide insight in opportunities to improve stroke systems of care. 

  Case Presentation:

A 62-year-old female with a past medical history of hypertension, current everyday tobacco smoker, and marijuana user presented to an outlying emergency department (ED) with dense left-sided hemiplegia affecting the arm and leg, right-sided gaze preference, and severe dysarthria. Her last known well (LKW) time was 0900 hours. CNS imaging revealed a right middle cerebral artery occlusion, visible to members of the CSC stroke team through the use of a cloud-based artificial intelligence cell phone application. The patient was treated with intravenous thrombolytics at the PSC, and she was transferred to the CSC, where she underwent a diagnostic cerebral arteriogram with carotid artery stenting. Later, Magnetic Resonance Imaging (MRI) of the brain revealed a 3.5 cm x 2.5 cm hemorrhagic lesion in the right frontal lobe and diffusion restriction in the right frontal and right posterior temporal lobes. The patient’s hospital stay was three days and, at the time of discharged, her modified Rankin score and NIHSS were zero. She was discharged on dual antiplatelet therapy, statin therapy, and nicotine replacement. 

Utilization of Artificial Intelligence:

            Transfer delays are complicated by organizing care at PSC and CSC and can be lengthy when communication across different facilities and subspecialties. Implementing cloud-based AI image sharing in stroke systems of care has reduced DIDO times by providing rapid imaging interpretation, streamlining communication, and enhancing coordination between PSCs and CSCs. 

Conclusions:

Our case presentation showed how a hub-and-spoke model combined with cloud-based AI utilization can improve DIDO times and enhance stroke systems of care.

Article Details

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