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Cerebrovascular Accident

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Title: Cerebrovascular Accident


1
Cerebrovascular AccidentBrain Attack
  • Prof Mohammad Salah Abduljabbar

2
Objectives
  • Define cerebrovascular accident and associated
    terminology
  • Discuss related pathophysiology and presentation
    of various types of stroke
  • Discuss etiology, risk factors, diagnostics,
    management, and outcomes of stroke
  • Review case studies and nursing diagnoses,
    interventions, and goals

3
Definition
  • Stroke or brain attack is an acute CNS injury
    that results in neurologic Symptoms and signs
    brought on by a reduction or absence of perfusion
    to a territory of the brain. The disruption in
    flow is from either an occlusion (ischemic) or
    rupture (hemorrhagic) of the blood vessel.

4
Incidence Prevalence
  • Third leading cause of death in the USA
  • 750,000 people/year
  • 175,000 die within one year (25)
  • Leading cause of long-term disabilities
  • 5.5 million survivors (USA)
  • 15 to 30 live with permanent disability

5
Stroke Statistics
  • 15 of adults gt age 50 cannot name a single
    symptom of stroke
  • 13 hours after onset of symptoms is the median
    time to presentation
  • 58 of stroke patients dont present during the
    first 24 hours after onset
  • 52 of stroke patients in the ED are unaware that
    they are experiencing a stroke

6
Classification
  • Cerebrovascular Accident
  • Ischemic Stroke
  • Thrombotic
  • Embolic
  • Lacunar infarct
  • TIA
  • Hemorrhagic Stroke
  • ICH
  • SAH

7
Stroke Knowledge
  • MYTHS
  • Cant prevent stroke
  • Cant treat stroke
  • Stroke affects the heart
  • Stroke affects the elderly
  • Recovery happens for a few months after stroke
  • FACTS
  • Stroke is preventable
  • Stroke is treatable
  • Stroke is a brain attack
  • Stroke affects anyone
  • Stroke recovery occurs throughout life

8
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9
Stroke Emergency Care
10
Stroke Symptoms
  • Sudden numbness or weakness of face, arm or leg,
    especially on one side of the body
  • Sudden confusion, trouble understanding or
    speaking
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of
    balance or coordination
  • Sudden severe headache with no known cause

11
Other Symptoms
  • Sudden nausea, fever and vomiting, distinguished
    from a viral illness by rapid onset (minutes or
    hours vs. days)
  • Brief loss of consciousness or period of
    decreased consciousness
    (fainting, confusion, convulsions or coma)

12
Cerebral Ischemia
  • Embolism
  • Abrupt onset
  • Small vascular area
  • Focal deficit
  • Pure aphasia
  • Pure hemianopia
  • Acute CT normal
  • High recurrence risk
  • Thrombosis
  • Preceded by TIAs
  • Abrupt onset
  • Large vascular area
  • More complex symptoms
  • Acute CT normal

13
Thrombotic Stroke
  • Occlusion of large cerebral vessel
  • Older population
  • Sleeping/resting
  • Rapid event, but slow progression (usually reach
    max deficit in 3 days)

14
Embolic Stroke
  • Embolus becomes lodged in vessel and causes
    occlusion
  • Bifurcations are most common site
  • Sudden onset with immediate deficits
  • Hemorrhagic Transformation

15
Lacunar Strokes - 20 of all stokes
  • Minor deficits
  • Paralysis and sensory loss
  • Lacune
  • Small, deep penetrating arteries
  • High incidence
  • Chronic hypertension
  • Elderly
  • DIC

16
Lacunar Strokes
  • 15 20 of ischemic strokes
  • Small penetrating branches of circle of Willis,
    MCA, or vertebrobasilar artery
  • Atherothrombotic or lipohyalinotic occlusion
  • Infarct of deep brain structures
  • Basal ganglia, cerebral white matter, thalamus,
    pons, and cerebellum
  • From 3 mm to 2 cm

17
Lacunar Stroke Syndromes
  • Well-defined syndromes
  • Pure motor hemiparesis (with dysarthria)
  • Pure sensory stroke (loss or paresthesias)
  • Dysarthria-clumsy hand (with contralateral face
    and tongue weakness)
  • Ataxia-hemiparesis (contralateral face and leg
    weakness)
  • Isolated motor-sensory stroke

18
  • Risk factors
  • Diabetes
  • Hypertension
  • Polycythemia
  • Variable course progressing over days
  • Fluctuating progressing in steps or remitting
  • Preceded by TIAs in 25
  • Without headache or vomiting

19
Remember Lacunar Strokes
20
Transient Ischemic Attack
  • Sudden, focal neurologic deficit lasting less
    than 24 hours, confined to an area of the brain
    or eye perfused by a specific artery.
  • Based on assumption that TIAs do not cause
    infarction or other permanent brain injury.
  • Time criterion is arbitrary.

21
Transient Ischemic Attack
  • Warning sign for stroke
  • Brief localized ischemia
  • Common manifestations
  • Contralateral numbness/
  • weakness of hand, forearm, corner of mouth
  • Aphasia
  • Visual disturbances- blurring
  • Deficits last less than 24 hours (usually less
    than 1 or 2 hrs)
  • Can occur due to
  • Inflammatory artery disorders
  • Sickle cell anemia
  • Atherosclerotic changes

22
TIA - Differential Diagnosis
  • Anxiety (panic attack)
  • Hyperventilation
  • Neuropathy (focal)
  • Neuropathy (ischemic)
  • Vertigo
  • Disequilibrium
  • Migraine
  • Orthostatic hypotension
  • Syncope
  • Arrhythmias (ischemia)
  • Seizures
  • Conversion disorder

23
Hemorrhagic Stroke Definitions
  • Intracerebral hemorrhage
  • Intracranial hemorrhage
  • Parenchymal hemorrhage
  • Intraparenchymal hematoma
  • Contusion
  • Subarachnoid hemorrhage

24
Cerebral Hemorrhage
  • Epidural hemorrhage
  • Smooth onset
  • Arterial origin
  • Mass effect causes coma over hours
  • Similar (but slower in evolution) to hemorrhage
    in basal ganglia
  • Subdural hemorrhage
  • Smooth onset
  • Venous origin
  • May be recurrent
  • Fluctuating, falsely localizing signs

25
Hemorrhagic Stroke
  • Rupture of vessel
  • Sudden
  • Active
  • Fatal
  • HTN
  • Trauma
  • Varied manifestations

26
Hemorrhagic Stroke
  • Intracerebral
  • Hemorrhage
  • Subarachnoid
  • Hemorrhage

27
PathophysiologyHemorrhagic Stroke
  • Changes in vasculature
  • Tear or rupture
  • Hemorrhage
  • Decreased perfusion
  • Clotting
  • Edema
  • Increased intracranial pressure
  • Cortical irritation

28
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29
Legs
Voluntary Motor
Mom Bowel/bladder Reasoning/judgment Long term
memory
Sensations Pain Touch Taste
Arms Head
Vision visual memory
Hearing/association Smell taste
Short term Memory
Balance, Coordination of each muscle group
CN 5,6,7,8 P,R, B/P
CN 9,10,11,12 Tracks cross over Coordinate
movement, HR,B/P
30
Vessels of the Brain
31
Vessels of the Brain
Right Side
32
Circle of Willis
33
PhysiologyNormal Cerebral Blood Flow
  • Oxygen
  • Glucose
  • 20 of Cardiac Output / oxygen
  • Arterial supply to the brain
  • Internal carotid (anteriorly)
  • Vertebral arteries (posteriorly)
  • Venous drainage
  • 2 sets of veins - venous plexuses
  • Dural sinuses to internal jugular veins
  • Sagittal sinus to vertebral veins
  • No valves, depend on gravity and venous pressure
    gradient for flow

34
Risk Factors
  • NON-MODIFIABLE
  • MODIFIABLE
  • Age
  • 2/3 over 65
  • Gender
  • MF
  • Femalegtfatality
  • Race
  • AA gt hispanics, NA
  • Asians gt hem
  • Heredity
  • Family history
  • Previous TIA/CVA
  • Hypertension
  • Diabetes mellitus
  • Heart disease
  • A-fib
  • Asymptomatic carotid stenosis
  • Hyperlipidemia
  • Obesity
  • Oral contraceptive use
  • Heavy alcohol use
  • Physical inactivity
  • Sickle cell disease
  • Smoking
  • Procedure precautions

35
EtiologyIschemic Stroke
  • Prothrombotic states
  • Embolism
  • Atrial fib
  • Sinoatrial Disease
  • Recent MI
  • Endocarditis
  • Cardiac tumors
  • Valvular heart disease
  • Patent foramen ovale
  • Carotid/basilar artery stenosis
  • Atherosclerotic lesions
  • Vasculitis
  • Hemostatic regulatory protein abnormalities
  • Antiphospholipid antibodies
  • Hep cofactor II

36
Etiology Hemorrhagic Stroke
  • Chronic HTN
  • Cerebral Amyloid Angiopathy
  • Anticoagulation
  • AVM
  • Ruptured aneurysm (usually subarachnoid)
  • Tumor
  • Sympathomimetics
  • Infection
  • Trauma
  • Transformation of ischemic stroke
  • Physical exertion, Pregnancy
  • Post-operative

37
Aneurysm
  • Localized dilation of arterial lumen
  • Degenerative vascular disease
  • Bifurcations of circle of Willis
  • 85 anterior
  • 15 posterior

38
AneurysmSubarachnoid Hemorrhage
  • SAH
  • Mortality 70
  • 97 HA
  • Nuchal rigidity
  • Fever
  • Photophobia
  • Lethargy
  • Nausea
  • Vomiting

39
Aneurysm/SAH
  • Complications
  • HCP
  • Vasospasm
  • Triple H Therapy
  • HTN
  • Hemodilution
  • Hypervolemia
  • Surgical treatment
  • Clip
  • Coil
  • INR

40
Nursing Management
  • Assessment
  • Monitoring
  • BP
  • TCDs
  • CBC
  • Preventing complications
  • Bowel program
  • DVT prophylaxis
  • Seizure prophylaxis
  • Psychological support
  • Discharge planning

41
Arteriovenous Malformations
  • AVM
  • Tangled mass of arteries and veins
  • Seizure or ICH

42
Presentation
  • Sudden onset
  • Focal neurological deficit
  • Progresses over minutes to hours
  • HA, N/V, ltltLOC, HTN
  • Depends on location

43
Treatment of AVM
  • Endovascular
  • Neurosurgery
  • Radiosurgery

44
Manifestationsby Vessel
  • Vertebral Artery
  • Pain in face, nose, or eye
  • Numbness and weakness of face (involved side)
  • Gait disturbances
  • Dysphagia
  • Dysarthria (motor speech)

45
Manifestationsby Vessel
  • Internal carotid artery
  • Contralateral paralysis (arm, leg, face)
  • Contralateral sensory deficits
  • Aphasia (dominant hemisphere involvement)
  • Apraxia (motor task),
  • Agnosia (obj. recognition),
  • Unilateral neglect (non-dominant hemisphere
    involvement)
  • Homonymous hemianopia

46
Initial Stroke Assessment/Interventions
  • Neurological assessment NIH assessment
  • Call Stroke Alert Code
  • Ensure patient airway
  • VS
  • IV access
  • Maintain BP within parameters
  • Position head midline
  • ?HOB 30 (if no shock/injury)
  • CT, blood work, data collection/NIH Stroke Scale
  • Anticipate thrombolytic therapy for ischemic
    stroke

47
NIH Stroke Scale Score
  • Standardized method
  • measures degree of stroke r/t impairment and
    change in a patient over time.
  • Helps determine if degree of disability merits
    treatment with tPA.
  • As of 2008 stroke patients scoring greater than 4
    points can be treated with tPA.
  • Standardized research tool to compare efficacy
    stroke treatments and rehabilitation
    interventions.
  • Measures several aspects of brain function,
    including consciousness, vision, sensation,
    movement, speech, and language not measured by
    Glasgow coma scale.
  • Current NIH Stroke Score guidelines for measuring
    stroke severity
  • Points are given for each impairment.
  • 0 no stroke
  • 1-4 minor stroke
  • 5-15 moderate stroke
  • 15-20 moderate/severe stroke
  • 21-42 severe stroke
  • A maximal score of 42 represents the most severe
    and devastating stroke.

48
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50
Comic Relief
51
Question
  • The neurologic functions that are affected by a
    stroke are primarily related to
  • A. the amount of tissue area involved.
  • B. the rapidity of the onset of symptoms.
  • C. the brain area perfused by the affected
    artery.
  • D. the presence or absence of collateral
    circulation.

52
Question
  • A patient is admitted to the hospital with a left
    hemiplegia. To determine the size and location
    and to ascertain whether a stroke is ischemic or
    hemorrhagic, the nurse anticipated that the
    health care provider will request a
  • A. CT scan.
  • B. lumbar puncture.
  • C. cerebral angiogram.
  • D. PET scan.

53
Diagnosis
  • Tests for the Emergent Evaluation of the Patient
    with Acute Ischemic Stroke
  • CT head (-)
  • Electrocardiogram
  • Chest x-ray
  • Hematologic studies (complete blood count,
    platelet count, prothrombin time, partial
    thromboplastin time)
  • Serum electrolytes
  • Blood glucose
  • Renal and hepatic chemical analyses
  • National Institute of Health Scale (NIHSS) score

54
Diagnosis
  • Ischemic Stroke
  • Hemorrhagic Stoke

55
Medical Management
  • BP
  • MAP
  • CPP
  • Factor VII, Vit K, FFP
  • ICP
  • HOB
  • Sedation
  • Osmotherapy
  • Hyperventilation
  • Paralytics
  • Fluid management
  • euvolemia
  • Seizure prophylaxis
  • Keppra
  • Dilantin
  • Sedation
  • Body temperature
  • PT/OT/ST
  • DVT prophylaxis

56
Treatment
  • Ischemic
  • Hemorrhagic
  • Medical management
  • TPA
  • Endovascular
  • Carotid endarectomy
  • Merci clot removal
  • http//youtu.be/P2TNz-TniIA
  • Medical management
  • Decompression
  • Craniotomy
  • Craniectomy

PT/OT/ST REHABILITATION
57
Medications
  • Anti-coagulants A fib TIA
  • Antithrombotics
  • Calcium channel blockers Nimotop (nimodipine)
  • Corticosteroids ???
  • Diuretics Mannitol, Lasix (Furosemide)
  • Anticonvulsants Dilantin (phenytoin) or Cerebyx
    (Fosphenytoin Sodium Injection)
  • Thrombolytics - tPA (recombinant tissue
    plasminogen activator)

58
Medications
  • Thrombolytics Recombinant Alteplase (rtPA)
    Activase, Tissue plasminogen activator
  • Treatment must be initiated promptly after CT to
    R/O bleed
  • Systemic within 3 hours of onset of symptoms
  • Intra-arterial within 6 hours of symptoms
  • Some exclusions
  • Seizure at onset
  • Subarachnoid hemorrhage
  • Trauma within 3 months
  • History of prior intracranial hemorrhage
  • AV malformation or aneurysm
  • Surgery 14 days, pregnancy,
  • Cardiac cath. 7 days

59
Neurosurgical Management
  • Craniotomy
  • Craniectomy
  • EVD placement
  • ICP monitor placement

60
Recommendations for Surgical Treatment of ICH
  • Nonsurgical candidates
  • Small hemorrhage
  • Minimal deficit
  • GCS lt/ 4 (unless brain stem compression)
  • Loss of brainstem reflexes
  • Severe coagulopathy
  • Basal ganglion or thalamic
  • Surgical candidates
  • gt3cm
  • Neuro deficit
  • Brain stem compression
  • MLS, HCP
  • Aneurysm, AVM, cavernous hemangioma
  • Young c mod/large lobar hemorrhage c clinical
    deterioration

61
Reducing Primary Risk
  • Obstructive sleep apnea
  • Homocysteine ? folate, B6, B12
  • Hypertension morning BP surge
  • Smoking ? 50 risk reduction in 1 yr
  • Hyperlipidemia ? statins
  • Migraine ? triptans
  • Drugs cocaine, ephedra, PPA

62
Reducing Primary Risk
  • Asymptomatic carotid stenosis
  • Endarterectomy for gt 60 stenosis
  • Risk reduction for 3 to 1 per year
  • Benefit related to surgical risk
  • Nonvalvular atrial fibrillation
  • Aspirin for patients lt 65 years, healthy
  • Warfarin for patients gt 65 years or having other
    stroke risk factors

63
Reducing Secondary Risk
  • Reducing risk of recurrence
  • TIA with ipsilateral carotid stenosis ?
    endarterectomy for gt 70 stenosis
  • Cardiogenic embolism ? warfarin
  • Lacunar infarcts ? aspirin, dipyridamole
  • Cryptogenic infarcts (40 embolic) ?
    anticoagulation?

64
Reducing Risk in Children
  • Sickle cell disease
  • Screen with transcranial doppler q 6 mo
  • Transfusion therapy for 2 abnormal studies
  • Congenital heart disease
  • Arterial dissections (trauma)
  • Prothrombotic disorders
  • Mitochondria disorders (MELAS)

65
Using Statins
  • Pooled results after 5 years
  • Pravastatin or Simvastatin 40 mg/day
  • Changes in cholesterol levels
  • Total cholesterol decreased 20
  • LDL cholesterol decreased 28
  • HDL cholesterol increased 5
  • Triglycerides decreased 13

66
Using Statins
  • Reducing LDL cholesterol by 1 mmol/L
  • 22 stroke reduction in patients with known
    vascular disease
  • 6 stroke reduction in patients without known
    vascular disease
  • 28 reduction in thromboembolic stroke

67
Complications
  • Increased intracranial pressure
  • Rebleeding
  • Vasospasm
  • HCP
  • Death

68
Outcomes
  • Age
  • Size, volume
  • Location
  • HCP, IVH
  • Deficit, LOC, MAP
  • Duration
  • Co-morbidities
  • 44 mortality

69
References
  • AANN Core Curriculum for Neuroscience Louis, MO.
    Nursing, 4th Ed. 2004. Saunders. St.
  • Broderick, J., et. al. (1999) Guidelines for the
    management of spontaneous intracerebral
    hemorrhage. AHA.
  • El-Mitwali, A., Malkoff, M. (2001) Intracerebral
    hemorrhage. The Internet Journal of
    Neurosurgery. 1.1.
  • Greenberg, Mark. (2006). Handbook of
  • Neurosurgery. Greenberg Graphics,
  • Tampa, Florida.
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