Treatment options for anticoagulated patients presenting with ischemic stroke are limited. Off-label use of idarucizumab to rapidly reverse the anticoagulant effect of dabigatran may ensure eligibility for thrombolytic therapy with alteplase. This case describes a 77-year-old white male who presented to the hospital 89 minutes after sudden onset of right-sided hemiparesis, dysarthria, and facial palsy. Significant history included atrial fibrillation and previous right-sided cortical stroke. Medication reconciliation revealed he was taking dabigatran 150 mg twice a day, with the last dose being 179 minutes before presentation. Neuroimaging revealed no new infarct or hemorrhage, and 60 minutes after arrival, a decision was made to give idarucizumab to reverse the anticoagulant effect of dabigatran. In the absence of any contraindication, he was then treated with intravenous alteplase and idarucizumab. No adverse outcomes were noted, and at discharge, his new stroke symptoms were completely resolved.
Background: Ischaemic stroke accounts for 87% of strokes and occurs when a clot or a thrombus blocks a blood vessel, cutting off blood flow to a part of the brain. If large areas of brain are affected, spaceoccupying oedema may result, leading to rapid neurological deterioration, coma and death. Malignant middle cerebral artery infarction (MMCAI) is a life-threating ischaemic stroke involving the whole middle cerebral artery (MCA) territory and comprises up to 10% of MCA infarctions. Methods: We report the case of a 62 year old female 'Mary' who presented with a MMCAI together with a summary of the most recent and relevant evidence for treatment options in terms of survival and quality of life for her. We also focus on the vital role of the nurse in Mary's care and treatment. Results: Intravenous thrombolysis and endovascular clot retrieval (ECR) during the hyperacute phase have been shown to improve outcomes but Mary did not meet the criteria for thrombolysis and received unsuccessful ECR. Her neurological condition deteriorated so she underwent surgical decompression, which is one of the major advances for MMCAI treatment together with expert neuro critical care nursing. Mary made a good functional recovery, returning home to live independently. Conclusion: This case highlights the need to consider all contextual and patient preferences in relation to treatment options. In addition the case emphases the vital role the neuro critical care nurse specialist plays in the complex assessment and treatment of this patient who experienced a MMCAI and underwent complex interventions.
The ‘In Safe Hands” (ISH) is a structured interdisciplinary bedside round developed to increase patients participation in their care in acute hospital wards. This has shown to improve quality of care by reducing communication errors and complications, enhancing a culture of safety in an acute hospital. The purpose of this study was to assess the effect of ISH on length of stay (LOS), in-hospital complications and assess whether the ISH enhances patient and staff satisfaction in a stroke unit of a tertiary hospital in Sydney, Australia. This was a longitudinal study pre and post implementation. A total of 200 patients participated in the study. Data on the length of stay, incidence rate relating to patient safety and patient and staff satisfaction surveys using Patient Experience Tracker (PET) devices were collected pre and post implementation. ISH increased the number of patients with at least 72hours in stroke unit care by 80 percent (P < 0.001). Fever and hyperglycaemia were treated in all patients following ISH implementation vs only 50% and 64% respectively of patients pre ISH implementation. Swallow screen was completed in all patients prior oral intake compared to 92% of patients of the pre ISH group (P = 0.03). There was no significant difference in the LOS and complications. All stroke patients received stroke education and there were no readmissions post implementation. There was no significant difference in the patient and staff satisfaction. In conclusion, although ISH did not improve the primary endpoints of LOS, complications and satisfaction it did improve protocol adherence.
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