cerebrovascular accident “brain attack”

Cerebrovascular Accident“Brain Attack”

Lisa Randall, RN, MSN, ACNS-BCRNSG 2432

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

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.

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

Definitions

Cerebrovascular Accident Ischemic Stroke

Thrombotic Embolic Lacunar infarct TIA

Hemorrhagic Stroke ICH SAH

Stroke: Emergency Care

• http://youtu.be/-d8__FkW-nU

Thrombotic Stroke

• Occlusion of large cerebral vessel

• Older population• Sleeping/resting• Rapid event, but slow

progression (usually reach max deficit in 3 days)

Embolic Stroke• Embolus becomes lodged in vessel

and causes occlusion• Bifurcations are most common site• Sudden onset with immediate

deficits– Embolysis

– Hemorrhagic Transformation

Lacunar Strokes - 20% of all stokes • Minor deficits

– Paralysis and sensory loss• Lacune • Small, deep penetrating arteries • High incidence:

– Chronic hypertension – Elderly– DIC

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

Hemorrhagic Stroke Definitions

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

Hemorrhagic Stroke

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

Hemorrhagic Stroke

– Intracerebral Hemorrhage

– Subarachnoid Hemorrhage

PathophysiologyHemorrhagic Stroke

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

Hearing/association & Smell & taste Short term Memory

Voluntary Motor

Sensations Pain & Touch Taste

Balance, Coordination of each muscle group

Arms

Head

LegsMom: Bowel/bladder Reasoning/judgment Long term memory

Vision & visual memory

CN 5,6,7,8 P,R, B/P CN 9,10,11,12

Tracks cross over Coordinate movement, HR,B/P

Vessels of the Brain

Vessels of the Brain

Right Side

Circle of Willis

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

Risk Factors

NON-MODIFIABLE Age

2/3 over 65 Gender

M=F Female>fatality

Race AA > hispanics, NA Asians > hem

Heredity Family history Previous TIA/CVA

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

EtiologyIschemic Stroke

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

Prothrombotic states• Hemostatic regulatory

protein abnormalities• Antiphospholipid antibodies• Hep cofactor II

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

Aneurysm

• Localized dilation of arterial lumen• Degenerative vascular disease• Bifurcations of circle of Willis

– 85% anterior– 15% posterior

AneurysmSubarachnoid Hemorrhage

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

Aneurysm/SAH Complications

HCP Vasospasm

Triple H Therapy HTN Hemodilution Hypervolemia

Surgical treatment Clip Coil INR

Nursing Management Assessment Monitoring

BP TCDs CBC

Preventing complications Bowel program DVT prophylaxis Siezure prophylaxis Psychological support Discharge planning

Arteriovenous malformations

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

Treatment AVM

• Endovascular• Neurosurgery• Radiosurgery

Presentation

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

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.

Manifestationsby Vessel

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

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

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


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


• 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


• Integument– Pressure ulcers

• Respiratory– Respiratory center damage– Airway obstruction– Decreased cough ability

• GI– Dysphagia– Constipation– Stool impaction

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

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.

Comic Relief

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.

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.

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

Diagnostics

Ischemic Stroke Hemorrhagic Stoke

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

Treatment

Ischemic• Medical management• TpA• Endovascular

– Carotid endarectomy– Merci clot removal

• http://youtu.be/P2TNz-TniIA

Hemorrhagic• Medical management• Decompression

– Craniotomy– Craniectomy

PT/OT/STREHABILITATION

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)

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

Neurosurgical Management

• Craniotomy• Craniectomy• EVD placement• ICP monitor placement

Recommendations for Surgical Treatment of ICH

• Nonsurgical candidates– Small hemorrhage– Minimal deficit– GCS </= 4 (unless brain

stem compression)– Loss of brainstem fxn– Severe coagulopathy– Basal ganglion or thalamic

• Surgical candidates– >3cm

• Neuro deficit• Brain stem compression• MLS, HCP

– Aneurysm, AVM, cavernous hemangioma

– Young c mod/large lobar hemorrhage c clinical deterioration

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.

Standing Orders

• Per facility policy

Nursing Concerns

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

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

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.

Overview

http://youtu.be/-d8__FkW-nU

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.

Nursing Diagnosis

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

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


• Ineffective Tissue Perfusion (cont)

• Monitor strength/reflexes• Assess for HA, sluggish pupils, posturing• Monitor cardiac status• Monitor I&O’s

– Can get DI as result of pituitary gland damage

• Monitor seizure activity


• 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


• Impaired Physical MobilityFlaccidity & 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)


• 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

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 don’t understand what the client is saying, let them

know, and have them try again


• 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


• 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

Question A patient with a right hemisphere stroke has a

nursing diagnosis of unilateral neglect R/T sensory-perceptual deficits. During the patient’s rehabilatation, it is important for the nurse to A. avoid positioning the patient on the affected side. B. place all objects for care on the patient’s

unaffected side. C. teach the patient to care consciously for the

affected side. D. protect the affected side from injury with pillows

and supports.

Complications

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

Outcomes

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

• 44% mortality

Evaluation

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

Patient/Family Education PREVENTION is key

Smoking cessation Physical activity

Weight reduction Diet

Plavix LDL chol reduction

Statins > HDL

BP normilization ACE inhibitos ARB Thiazide diuretics

Antiplatelet agents ASA

DM ETOH Homocysteine reduction

http://youtu.be/awtFZQkoBPc

Legal/Ethical Concerns

• Advanced directives– MPOA

• Category status• Code status• Withdrawal of care• Palliative care• Placement

Resourceswww.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_Stroke_Scale.pdf -- NIH stroke scoring system www.strokecenter.org/trials -- Find a clinical trial on stroke

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

Jackson, William JJ^31725511/12/19751/12/197534 YEAR34 YEARMM

Page: 14 of 36Page: 14 of 36------Acq No: 4Acq No: 4eff. mAs: 460eff. mAs: 460mA: 460mA: 460KVp: 120KVp: 120Tilt: -10Tilt: -10RD: 250RD: 250512x512512x512

BRACKENRIDGE BRACKENRIDGECT Head w/o ContrastCT Head w/o Contrast

Head W/O ST.Head W/O ST. 12/3/2009 6:43:15 AM 12/3/2009 6:43:15 AM

37258603725860------

LOC: -111.80LOC: -111.80THK: 4.80THK: 4.80

HFSHFS

IM: 14 SE: 2IM: 14 SE: 2Compressed 11:1Compressed 11:1

W: 80W: 80C: 35C: 35

RR LL

AA

PP

------

cm cm

Question

• The incidence of ischemic stroke in pateints 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).

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 includea. hyperventilation therapy.b. surgical clipping of the aneurysm.c. administration of hypersomotic agents.d. administration of thrombolytic therapy.

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.

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 patient’s 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.

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.

cerebrovascular accident “brain attack”

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