Cerebrovascular Accident

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Cerebrovascular AccidentBrain Attack

• Prof Mohammad Salah Abduljabbar

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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

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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.

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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

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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

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Classification

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

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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

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Stroke Emergency Care
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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

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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)

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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

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Thrombotic Stroke

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

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Embolic Stroke

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

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Lacunar Strokes - 20 of all stokes

• Minor deficits
• Paralysis and sensory loss
• Lacune
• Small, deep penetrating arteries
• High incidence
• Chronic hypertension
• Elderly
• DIC

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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

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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

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• 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

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Remember Lacunar Strokes
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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.

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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

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TIA - Differential Diagnosis

• Anxiety (panic attack)
• Hyperventilation
• Neuropathy (focal)
• Neuropathy (ischemic)
• Vertigo
• Disequilibrium

• Migraine
• Orthostatic hypotension
• Syncope
• Arrhythmias (ischemia)
• Seizures
• Conversion disorder

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Hemorrhagic Stroke Definitions

• Intracerebral hemorrhage
• Intracranial hemorrhage
• Parenchymal hemorrhage
• Intraparenchymal hematoma
• Contusion
• Subarachnoid hemorrhage

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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

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Hemorrhagic Stroke

• Rupture of vessel
• Sudden
• Active
• Fatal
• HTN
• Trauma
• Varied manifestations

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Hemorrhagic Stroke

• Intracerebral
• Hemorrhage
• Subarachnoid
• Hemorrhage

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PathophysiologyHemorrhagic Stroke

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

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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
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Vessels of the Brain
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Vessels of the Brain
Right Side
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Circle of Willis
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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

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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

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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

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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

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Aneurysm

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

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AneurysmSubarachnoid Hemorrhage

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

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Aneurysm/SAH

• Complications
• HCP
• Vasospasm
• Triple H Therapy
• HTN
• Hemodilution
• Hypervolemia
• Surgical treatment
• Clip
• Coil
• INR

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Nursing Management

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

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Arteriovenous Malformations

• AVM
• Tangled mass of arteries and veins
• Seizure or ICH

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Presentation

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

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Treatment of AVM

• Endovascular
• Neurosurgery
• Radiosurgery

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Manifestationsby Vessel

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

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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

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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

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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.

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Comic Relief
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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.

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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.

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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

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Diagnosis

• Ischemic Stroke

• Hemorrhagic Stoke

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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

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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
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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)

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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

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Neurosurgical Management

• Craniotomy
• Craniectomy
• EVD placement
• ICP monitor placement

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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

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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

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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

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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?

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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)

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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

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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

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Complications

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

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Outcomes

• Age
• Size, volume
• Location
• HCP, IVH
• Deficit, LOC, MAP
• Duration
• Co-morbidities

• 44 mortality

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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.