This is a case of cerebrovascular accident in evolution. It means that the damage to the cerebrum is still in progress and is not completed. The rationale for the use of glucocorticoids is that glucocorticoids have a direct effect on the blood vessels and the heart. These effects influence vascular function, atherogenesis and vascular remodeling which follows intravascular injury or ischemia.
Based on the fact that Robert was not given tissue plasminogen activator, it points to the fact that the CVA is likely to be the hemorrhagic type as opposed to ischemic CVA in which tissue plasminogen activator is used.
The right side of the cerebrum was affected. This is due to the decussating at the medulla in which fibers from the right side cross over to the left side as they travel into the spinal cord.
Flaccid means that there is weakness in the limbs. It is generally noticed that spasticity occurs between 1 and 3 months post CVA patients. However, this can be militated by regular physiotherapy. The job of the physical therapist is to help Robert get back to physical shape with the best use of his body as much as the recovery process will allow. For example, exercises like partial body weight support treadmill training, electrical stimulation of the muscles, constraint-induced muscle training, robotic-assisted therapeutic exercise are some of the interventions that can be rendered by the physical therapist.
Occupational therapist will be responsible for restoring Robert back to his premorbid state so that he would be able to perform those tasks that he could perform before his CVA. Examples of such interventions induce training of cognitive function, training of sensory-motor functions and training of skills. Speech-language pathologist would help Robert get the best use of his speech as much as the recovery would allow it. For example, the pathologist could take Robert through Group Speech therapy with other patients; he could be engaged in conversational coaching, practice and training of his speech and guided computerized training among other things.
The social worker takes care of the psychological need of the patient. For example, the social worker is responsible for involving the family in the care of the patient, the social worker can also engage in psychotherapy with the patient.
Lynn’s Multiple Sclerosis
The likely diagnosis is multiple Sclerosis. Lynn has been having the attack for the past two weeks, the presence of 5 active plaques on MRI, the normal blood tests, the delayed VEP points to demyelination in the anterior visual pathways and also the cerebral fluid analysis which shows the presence of oligoclonal bands and also elevated IgG antibodies.
The cause of the disease is largely unknown, although it is said to be most likely a combination of genetic susceptibility and a nongenetic trigger which could either be a viral infection or low vitamin D levels. The nerves lose their myelin sheet - demyelination. There is also destruction of oligodendrocytes and reactive astrogliosis. However, the axon cylinder is often spared, but this may not be the case in some cases as the axon cylinder could be aggressively destroyed.
There is expression of Interleukin 12 in the early Multiple Sclerosis which is a potent promoter of inflammation. There is also decreased function of t-lymphocytes. There is some degree of cognitive deterioration in patients. There women-to-men prevalence is put at 2.4 showing that there is an increase in the number of female patients than male patients. The disease is not very common, with a 95 per 100,000 prevalence rate.
Lynn was given glucocorticoids to speed up recovery from exacerbations and acute relapses. The drug reverses the increased capillary permeability and suppresses neutrophil activity. These would reduce the level of inflammation that occurs during exacerbations. In the next two years, Lynn is going to have acute exacerbations at intervals after which she would get well before another episode occurs. The natural course of the disease leads to significant disability after about 25 years after the onset of the disease. However, with medical intervention, there could be a slowing down of this progression.
References
Christopher, Luzzio, Mark, Keegan (2012). Multiple Sclerosis. Medscape Reference. Accessed from
Christopher, Luzzio, Mark, Keegan (2012). Multiple Sclerosis Workup. Medscape Reference. Accessed from
Brian, Walker (2007). Glucocorticoids and Cardiovascular Disease. European Journal of Endocrinology 157 545-559. Accessed from
David, Liebeskind (2011). Hemorrhagic Stroke in Emergency Medicine. Medscape Reference. Accessed from
