1 / 66

Stroke ACNP Bootcamp 2012

Stroke ACNP Bootcamp 2012. Briana Witherspoon, MSN, ACNP-BC, CCRN, CNRN. Stroke Objectives. Review Ischemic Stroke Algorithm Identifying location of ischemic stroke Acute management of an ischemic stroke Acute management of hemorrhagic stroke. Stroke Algorithm. NIHSS.

blafreniere
Download Presentation

Stroke ACNP Bootcamp 2012

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. StrokeACNP Bootcamp 2012 Briana Witherspoon, MSN, ACNP-BC, CCRN, CNRN

  2. Stroke Objectives • Review Ischemic Stroke Algorithm • Identifying location of ischemic stroke • Acute management of an ischemic stroke • Acute management of hemorrhagic stroke

  3. Stroke Algorithm

  4. NIHSS • NIHSS (National Institute of Health Stroke Scale) • Standardized method used by health care professionals to measure the level of impairment caused by a stroke • Purpose • Main use is as a clinical assessment tool to determine whether the degree of disability is severe enough to warrant the use of tPA • Another important use of the NIHSS is in research, where it allows for the objective comparison of efficacy across different stroke treatments and rehabilitation interventions • Scores are totaled to determine level of severity • Can also serve as a tool to determine if a change in exam has occurred

  5. Breaking Down the Scale • 13 item scoring system, 7 minute exam • Integrates neurologic exam components • CN (visual), motor, sensory, cerebellar, inattention, language, LOC • Maximum score is 42, signifying severe stroke • Minimum score is 0, a normal exam • Scores greater than 15-20 are more severe

  6. NIHSS cont. • NIHSS Interpretation

  7. NIHSS and Outcome Prediction • NIHSS below 12-14 will have an 80% good or excellent outcome. • NIHSS above 20-26 will have less than a 20% good or excellent outcome. • Lacunar infarct patients had the best outcomes. Adams HP Neurology 1999;53:126-131 Baseline NIH Stroke Scale score strongly predicts outcome after stroke (TOAST)

  8. Etiology of Ischemic Strokes LARGE VESSEL THROMBOTIC: Virchow’s Triad…. • Blood vessel injury • HTN, Atherosclerosis, Vasculitis • Stasis/turbulent blood flow • Atherosclerosis, A. fib., Valve disorders • Hypercoagulable state • Increased number of platelets • Deficiency of anti-coagulation factors • Presence of pro-coagulation factors • Cancer

  9. Etiology Of Stroke: LARGE VESSEL EMBOLIC: • The Heart • Valve diseases, A. Fib, Dilated cardiomyopathy, myxoma • Arterial Circulation (artery to artery emboli) • Atherosclerosis of carotid, Arterial dissection, Vasculitis • The Venous Circulation • PFO w/R to L shunt, Fat, air, or septic emboli

  10. Determining the Location • Large Vessel: • Look for cortical signs • Small Vessel: • No cortical signs on exam • Posterior Circulation: • Crossed signs • Cranial nerve findings • Watershed: • Look at watershed and borderzone areas • Hypo-perfusion

  11. Cortical Signs • If present, think LARGE VESSEL stroke

  12. Large Vessel Stroke Syndromes • MCA: • Arm>leg weakness • LMCA cognitive: Aphasia • RMCA cognitive: Neglect, anosognosia, topographical difficulty, apraxia, constructional impairment • ACA: • Leg>arm weakness, grasp • Cognitive: muteness, perseveration, abulia, disinhibiition • PCA: • Hemianopia • Cognitive: memory loss/confusion, alexia • Cerebellum: • Ipsilateral ataxia

  13. Circle of Willis

  14. Aphasia • Broca’s • Expressive aphasia • Left posterior inferior frontal gyrus • Wernicke’s • Receptive aphasia • Posterior part of the superior temporal gyrus • Located on the dominant side (left) of the brain

  15. Case 1 • 71 year old female with sudden onset of left-sided weakness • She was out with her sisters when she suddenly slumped her head and appeared to have a left facial droop • History of HTN and atrial fibrillation • Meds: Losartan

  16. Case 1 • BP- 142/83, P– 104, T- 98.0, RR– 22, O2- 94% • General exam: Unremarkableexcept irregular rate and rhythm • NEURO EXAM: - Speech dysarthricbut language intact - Right gaze preference - Left facial droop - Left- sided hemiplegia - Neglect - DTR's are symmetric, Left toe up

  17. Case 1

  18. Case 1

  19. Case 1

  20. Case 1

  21. Case 1 • Right MCA infarct, most likely cardioembolic from atrial fibrillation • Patient underwent mechanical thrombectomy with intra-arterial verapamil, clot removal successful • Excellent recovery – patient was discharged 48 hours later on Coumadin

  22. Determining the Location • Large Vessel: • Look for cortical signs • Small Vessel: • No cortical signs on exam • Posterior Circulation: • Crossed signs • Cranial nerve findings • Watershed: • Look for watershed pattern • S/S of Hypo-perfusion

  23. Etiology of Stroke SMALL VESSEL (Lacunes <1.5cm) • Risk Factors • HTN • HLD • DM • Tobacco Use • Sleep apnea

  24. Case 2 • 65 year old male with acute onset of left face, arm, and leg numbness • History of HTN, DM, and tobacco use • Meds: Insulin, aspirin

  25. Case 2 • BP- 168/96, P– 92 • General exam: Unremarkable, RRR • NEURO EXAM: - Decreased sensation on left face, arm, and leg

  26. Case 2

  27. Case 2 • Right thalamic lacunar infarct

  28. Determining the Location • Large Vessel: • Look for cortical signs • Small Vessel: • No cortical signs on exam • Posterior Circulation: • Crossed signs • Cranial nerve findings • Watershed: • Look at watershed and borderzone areas • Hypo-perfusion

  29. Brainstem Stroke Syndromes • Rarely presents with an isolated symptom • Usually a combination of cranial nerve abnormalities, and crossed motor/sensory findings, such as: • Double vision • Facial numbness and/or weakness • Slurred speech • Difficulty swallowing • Ataxia • Vertigo • Nausea and vomiting • Hoarseness

  30. Case 3 • 55 year old male with acute onset of right sided numbness and tingling, left sided face pain and numbness, gait imbalance, nausea/vomiting, vertigo, swallowing difficulties, and hoarse speech • History of CAD s/p CABG, DM2, HTN, HLD, OSA • Meds: Aspirin, plavix, insulin, lipitor, metoprolol, lisinopril

  31. Case 3 • NEURO EXAM: BP- 194/102, P– 105 • General exam: Unremarkable, RRR • NEURO EXAM: - Decreased sensation on left face - Decreased sensation on right body - Left ataxia on FNF, and unsteady gait - Voice hoarse - Nystagmus

  32. Case 3

  33. Case 3

  34. Case 3 • Brainstem Stroke

  35. Determining the Location • Large Vessel: • Look for cortical signs • Small Vessel: • No cortical signs on exam • Posterior Circulation: • Crossed signs • Cranial nerve findings • Watershed: • Look for the watershed pattern • Think about reasons of hypo-perfusion • Hypotension • Stenosed vessel, etc

  36. Case 4 • 56 year old female who upon waking post-op after elective surgery was found to have L sided weakness and neglect • History of HTN

  37. Case 4 • BP- 132/74, P– 84 • General exam: Unremarkable, RRR • NEURO EXAM: - Left face, arm, and leg weakness - Neglect - DTR’s brisk on the left, toe up on left

  38. Case 4

  39. Case 4

  40. Case 4

  41. Case 4

  42. Case 4

  43. Case 4

  44. Case 4

  45. Case 4 • Right hemisphere watershed infarct secondary to hypoperfusion in the setting of Right ICA stenosis • On review of anesthesia records, blood pressure dropped to 82/54 during the procedure

  46. Intracranial Hemorrhages

  47. Causes of ICH • Traumatic • Spontaneous • Hypertensive • Amyloid angiopathy • Aneurysmal rupture • Arteriovenous malformation rupture • Bleeding into tumor • Cocaine and amphetamine use

  48. Causes of ICH

  49. Hypertensive ICH • Spontaneous rupture of a small artery deep in the brain • Typical sites • Basal Ganglia • Cerebellum • Pons • Typical clinical presentation • Patient typically awake and often stressed, then abrupt onset of symptoms with acute decompensation

More Related