Cerebrovascular Accident

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Cerebrovascular AccidentBrain Attack

• Lisa Randall, RN, MSN, ACNS-BC
• RNSG 2432

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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 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.

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Definitions

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

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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 Emergency Care

• http//youtu.be/-d8__FkW-nU

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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
• Embolysis
• 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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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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EtiologyIschemic Stroke

• Prothrombotic states

• Embolism

• Atrial fib
• Sinoatrial D/O
• Recent MI
• Endocarditis
• Cardiac tumors
• Valvular D/O
• Patent foramen ovale
• Carotid/basilar artery stenosis
• Atherosclerotic lesions
• Vasculitis

• Hemostatic regulatory protein abnormalities
• Antiphospholipid antibodies
• Hep cofactor II

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Hemorrhagic Stroke Definitions

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

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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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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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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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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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Arteriovenous malformations

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

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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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Presentation

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

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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.

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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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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

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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

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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

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Manifestations Complications by Body System

• Integument
• Pressure ulcers
• Respiratory
• Respiratory center damage
• Airway obstruction
• Decreased cough ability
• GI
• Dysphagia
• Constipation
• Stool impaction

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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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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

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Diagnostics

• Ischemic Stroke

• Hemorrhagic Stoke

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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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Nursing Management

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

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Treatment

• Endovascular
• Neurosurgery
• Radiosurgery

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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 fxn
• 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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Nursing Concerns

• Medical management!
• Post-op care
• Mobilization
• Nutrition
• Constipation
• Skin

• Infection
• Patient/family teaching
• Follow-up
• Medications
• Resources available

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Standing Orders

• Per facility policy

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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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Question

• A carotid endarectomy is being considered as
  treatment for a patient who has had several TIAs.
  The nurse explains to the patient that this
  surgery
• A. is used to restore blood circulation to the
  brain following an obstruction of a cerebral
  artery.
• B. involves intracranial surgery to join a
  superficial extracranial artery to an
  intracranial artery.
• C. involves removing an atherosclerotic plaque in
  the carotid artery to prevent an impending
  stroke.
• D. is used to open a stenosis in a carotid artery
  with a balloon and stent to restore cerebral
  circulation.

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Question

• An essential intervention in the emergency
  management of the patient with a stroke is
• A. intravenous fluid replacement.
• B. administration of osmotic diuretics to reduce
  cerebral edema.
• C. initiation of hypothermia to decrease oxygen
  needs of the brain.
• D. maintenance of respiratory function with a
  patent airway and oxygen administration.

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Overview

• http//youtu.be/-d8__FkW-nU

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NCLEX

• A patient comes to the ED immediately after
  experiencing numbness of the face and inability
  to speak, but while the patient awaits
  examination, the symptoms disappear and the
  patient requests discharge. The RN stresses that
  it is important for the patient to be evaluated,
  primarily because
• A. the patient has probably experienced an
  asymptomatic lacunar stroke.
• B. the symptoms are likely to return and progress
  to worsening neurologic deficit in the next 24
  hours.
• C. neurologic deficits that are transient occur
  most often as a result of small hemorrhages that
  clot off.
• D. the patient has probably experienced a TIA
  that is a sign of progressive vascular disease.

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Nursing Diagnosis

• Ineffective cerebral tissue perfusion
• Impaired mobility
• Self-care deficit
• Impaired verbal communication
• Impaired swallowing

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Nursing Diagnoses/Interventions

• Ineffective Tissue Perfusion
• Goal is to maintain cerebral perfusion
• Monitor respiratory status
• Auscultate, monitor lung sounds
• Suction as needed increases ICP
• Place in side-lying position (secretions)
• O2 as needed/prescribed
• Assess LoC, other neuro vital signs
• NIH Stroke Scale
• Glasgow Coma Scale Eyes, Verbal, Motor

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Nursing Diagnoses/Interventions

• Ineffective Tissue Perfusion (cont)
• Monitor strength/reflexes
• Assess for HA, sluggish pupils, posturing
• Monitor cardiac status
• Monitor IOs
• Can get DI as result of pituitary gland damage
• Monitor seizure activity

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Nursing Diagnoses/Interventions

• Impaired Physical Mobility
• Goal is to maintain and improve functioning
• Active ROM for unaffected extremities
• Passive ROM for affected extremities
• Q2 hr turns
• Assess for thrombophlebitis
• Confer with PT for movement and positioning
  techniques for each stage of rehab

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Nursing Diagnoses/Interventions

• Impaired Physical Mobility
• Flaccidity spasticity
• Meds used to treat spasticity
• Kemstro or Lioresal (baclofen)
• Valium (diazepam)
• Dantrium (dantrolene sodium)
• Zanaflex (tizanidine hydrochloride)
• New drugs being tried
• Neurontin (Gabapentin) Botox (botulinum toxin)

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Nursing Diagnoses/Interventions

• Self-Care Deficit
• Goals are to promote functional ability, increase
  independence, improve self-esteem
• Encourage use of unaffected arm in ADLs
• Self-dressing (using unaffected side to dress
  affected side first)
• Sling or support for affected arm
• Confer with OT for techniques to promote return
  to independence

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Nursing Diagnoses/Interventions

• Impaired Verbal Communication
• Goal is to increase communication
• Speak in normal tones unless there is a
  documented hearing impairment
• Allow adequate time for responses
• Face center client when speaking, speak simply
  and enunciate words
• If you dont understand what the client is
  saying, let them know, and have them try again

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Nursing Diagnoses/Interventions

• Impaired Verbal Communication (cont)
• Try alternate method of communication if needed
• Writing, computerized boards, etc
• Allow client anger and frustration at loss of
  previous functioning
• Allow client to touch (hands, arms), may be the
  only way of expressing (comfort, etc)
• If client has visual disturbances
• During initial phase of recovery, position where
  client can easily see you in later stages,
  client can be directed to adjust position for
  visual contact

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Nursing Diagnoses/Interventions

• Impaired Swallowing
• Goal is safety, adequate nutrition, and hydration
• Position client upright, using pureed less
  often or finely chopped soft foods
• Hot or cold food or thickened liquids
• Teach client to put food behind teeth on
  unaffected side and tilt head backwards
• Check for food pockets, especially on affected
  side
• Have suctioning equipment at bedside
• Minimize distractions while eating
• Never leave client with food etc. in mouth

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Question

• A patient with a right hemisphere stroke has a
  nursing diagnosis of unilateral neglect R/T
  sensory-perceptual deficits. During the patients
  rehabilitation, it is important for the nurse to
• A. avoid positioning the patient on the affected
  side.
• B. place all objects for care on the patients
  unaffected side.
• C. teach the patient to care consciously for the
  affected side.
• D. protect the affected side from injury with
  pillows and supports.

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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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Evaluation

• Reduce mortality and morbidity
• Baseline neurological function
• Outcomes
• Evidenced based practice

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Patient/Family Education

• PREVENTION is key
• Smoking cessation
• Physical activity
• Weight reduction
• Diet
• Plavix
• LDL chol reduction
• Statins
• gt HDL

• BP normalization
• ACE inhibitors
• ARB
• Thiazide diuretics
• Antiplatelet agents
• ASA
• DM
• ETOH
• Homocysteine reduction
• http//youtu.be/awtFZQkoBPc

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Case Study 1

• 34 yo AAM
• R temporoparietal ICH c IVH, HCP
• h/o L MCA ischemic
• Sentis protocol
• Coumadin (INR 13)
• Factor VII, Vit K
• Craniotomy
• ICP
• EVD x 2

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Legal/Ethical Concerns

• Advanced directives
• MPOA
• Category status
• Code status
• Withdrawal of care
• Palliative care
• Placement

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Question

• The incidence of ischemic stroke in patients with
  TIAs and other risk factors is reduced with the
  administration of
• A. furosemide (Lasix).
• B. lovastatin (Mevacor).
• C. daily low-dose aspirin (ASA).
• D. nimodipine (Nimotop).

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Question

• A diagnosis of a ruptured cerebral aneurysm has
  been made in a patient with manifestations of a
  stroke. The nurse anticipates that treatment
  options that would be evaluated for the patient
  include
• a. hyperventilation therapy.
• b. surgical clipping of the aneurysm.
• c. administration of hyperosmotic agents.
• d. administration of thrombolytic therapy.

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Question

• A nursing intervention that is indicated for the
  patient with hemiplegia is
• A. the use of a footboard to prevent plantar
  flexion.
• B. immobilization of the affected arm against the
  chest with a sling.
• C. positioning the patient in bed with each joint
  lower that the joint proximal to it.
• D. having the patient perform passive ROM of the
  affected limb with the unaffected limb.

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Question

• The nurse can assist the patient and the family
  in coping with the long-term effects of a stroke
  by
• A. informing the family members that the patient
  will need assistance with almost all ADLs.
• B. explaining that the patients prestroke
  behavior will return as improvement progresses.
• C. encouraging the patient and family members to
  seek assistance from family therapy or stroke
  support group.
• D. helping the patient and family understand the
  significance of residual stroke damage to promote
  problem solving and planning.

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Resources www.stroke.org -- National Stroke
Association (800-787-6537) www.ninds.nih.gov --
National Institute of Neurological Disorders and
Stroke (800-352-9424) www.naric.com -- National
Rehabilitation Information Center (8003462742)
www.aphasia.org -- National Aphasia Association
(800-922-4622) www.aan.com -- American Academy
of Neurology www.dynamic-living.com -- Daily
living products www.ninds.nih.gov/doctors/NIH_Str
oke_Scale.pdf -- NIH stroke scoring system
www.strokecenter.org/trials -- Find a clinical
trial on stroke
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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.