Cerebrovascular Accident “Brain Attack”

1. Cerebrovascular Accident“Brain Attack” Lisa Randall, RN, MSN, ACNS-BC RNSG 2432

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 S/S 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. Definitions • Cerebrovascular Accident • Ischemic Stroke • Thrombotic • Embolic • Lacunar infarct • TIA • Hemorrhagic Stroke • ICH • SAH

7. Stroke: Emergency Care • http://youtu.be/-d8__FkW-nU

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

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

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

11. 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

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

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

14. Hemorrhagic Stroke • Intracerebral Hemorrhage • Subarachnoid Hemorrhage

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

17. Legs Mom: Bowel/bladder Reasoning/judgment Long term memory Voluntary Motor 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

18. Vessels of the Brain

19. Vessels of the Brain Right Side

20. Circle of Willis

21. 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

22. Risk Factors NON-MODIFIABLE MODIFIABLE 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 • Age • 2/3 over 65 • Gender • M=F • Female>fatality • Race • AA > hispanics, NA • Asians > hem • Heredity • Family history • Previous TIA/CVA

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

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

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

26. AneurysmSubarachnoid Hemorrhage • SAH • Mortality 70% • 97% HA • Nuchal rigidity • Fever • Photophobia • Lethargy • Nausea • Vomiting

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

28. Nursing Management • Assessment • Monitoring • BP • TCDs • CBC • Preventing complications • Bowel program • DVT prophylaxis • Siezure prophylaxis • Psychological support • Discharge planning

29. Arteriovenous malformations • AVM • Tangled mass of arteries and veins • Seizure or ICH

30. Treatment AVM • Endovascular • Neurosurgery • Radiosurgery

31. Presentation • Sudden onset • Focal neurological deficit • Progresses over minutes to hours • HA, N/V, <<LOC, HTN • Depends on location

32. Stroke Symptoms include: • SUDDEN numbness or weakness of face, arm or leg • SUDDEN confusion, trouble speaking or understanding. • SUDDEN trouble with vison. • SUDDEN trouble walking, dizziness, loss of balance or coordination. • SUDDEN severe HA.

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

34. 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

35. Manifestations & Complications by Body System • Neurological • Hyperthermia • Neglect syndrome • Seizures • Agnosias (familiar obj) • Communication deficits • Aphasia (expressive, receptive, global) • Agraphia • Visual deficits • Homonymous hemianopia • Diplopia • Decreased acuity • Decreased blink reflex

36. Manifestations & Complications by Body System • Neurological (cont.) • Cognitive changes • Memory loss • Short attention span • Poor judgment • Disorientation • Poor problem-solving ability • Behavioral changes • Emotional lability • Loss of inhibitions • Fear • Hostility

37. Manifestations & Complications by Body System • Musculoskeletal • Hemiplegia or hemiparesis • Contractures • Bony ankylosis • Disuse atrophy • Dysarthria - word formation • Dysphagia – swallow • Apraxia – complex movements • Flaccidity/spasticity • GU • Incontinence • Frequency • Urgency • Urinary retention • Renal calculi

38. Manifestations & Complications by Body System • Integument • Pressure ulcers • Respiratory • Respiratory center damage • Airway obstruction • Decreased cough ability • GI • Dysphagia • Constipation • Stool impaction

39. 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

40. 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.

43. Comic Relief

44. 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.

45. 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.

46. Diagnostics 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

47. Diagnostics Ischemic Stroke Hemorrhagic Stoke

48. 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

49. Treatment Ischemic Hemorrhagic Medical management Decompression Craniotomy Craniectomy • Medical management • TpA • Endovascular • Carotid endarectomy • Merci clot removal • http://youtu.be/P2TNz-TniIA PT/OT/ST REHABILITATION

50. 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)