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ACUTE STROKE
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  • 3 rd leading cause of death behind heart disease and cancer Of the 750,000 strokes 500,000 are first time attacks 200,000 are recurrent strokes. 28% of people who suffer a stroke in a given year are under age 65. 14% of people who have a stroke or TIA will have another within a year.
  • Thrombotic – Blood clot in an artery to the brain (artiosclerosis). Accounts for about 60% of all strokes. Embolic – Wandering clot that formed somewhere else (usually in heart or carotids) accounts for about 20% of all strokes. Systemic Hypoperfusion – (low blood flow) occurs as a result of circulatory failure ie: AMI.
  • Subarachnoid hemorrhage occurs when a blood vessel just outside the brain ruptures. The area of the skull surrounding the brain (the subarachnoid space) rapidly fills with blood. A patient with  subarachnoid hemorrhage may have a sudden, intense headache, neck pain, and nausea or vomiting.  Sometimes this is described as the worst headache of one's life. The sudden buildup of pressure outside the brain may also cause rapid loss of consciousness or death. Subarachnoid hemorrhage is most often caused by abnormalities of the arteries at the base of the brain, called cerebral aneurysms. These are small areas of rounded or irregular swellings in the arteries. Where the swelling is most severe, the blood vessel wall become weak and prone to rupture The cause of cerebral aneurysms is not known. They may develop from birth or in childhood and grow very slowly. Some people have not one, but several aneuryms.   Subarachnoid hemorrhage can occur at any age, including teenagers and young adults. Subarachnoid hemorrhage is slightly more common in women than men.
  • Intracerebral hemorrhage occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain.  (The name means within the cerebrum , or brain). The sudden increase in pressure within the brain can cause damage to the brain cells surrounding the blood. If the amount of blood increases rapidly, the sudden buildup in pressure can lead to unconsciousness or death.   Intracerebral hemorrhage usually occurs in selected parts of the brain, including the basal ganglia, cerebellum, brainstem, or cortex. The most common cause of intracerebral hemorrhage is high blood pressure (hypertension). Since high blood pressure by itself often causes no symptoms, many people with intracranial hemorrhage are not aware that they have high blood pressure, or that it needs to be treated. Less common causes of intracerebral hemorrhage include trauma, infections, tumors, blood clotting deficiencies, and abnormalities in blood vessels (such as arteriovenous malformations). Intracerebral hemorrhage occurs at all ages. The average age is lower than for ischemic stroke. Less common than ischemic strokes, hemorrhagic strokes make up about 12% of all strokes. Elevate HOB 30 degrees
  • Each year, 40,000 more women than men have strokes. Stroke or heart disease in parents younger than 60 years of age. Cardiac Disease – A fib, CHF, Cardiomyopathy, Valve disease, Cardiac procedures CCL
  • Homocysteine is an amino acid in the blood. Too much of it is related to a higher risk of coronary heart disease, stroke and peripheral vascular disease (fatty deposits in peripheral arteries). Evidence suggests that homocysteine may promote atherosclerosis (fatty deposits in blood vessels) by damaging the inner lining of arteries and promoting blood clots. However, a causal link hasn't been established. Folic acid and other B vitamins help break down homocysteine in the body.
  • (if bleed, Neurosurgeon contacted with STAT consult) (medical vs. IV t-PA vs. IA t-PA)
  • Activase
  • Should go to either 9WT or ICU first If patient received t-PA: NO IV starts NO Foley insertion No NG tubes Come to cardiac if on a Cardizem GTT for new onset AFib Remote tele for at least 24 hours.
  • Activity depends on degree of disability; First 24 hours HOB flat if ischemic, elevate 30 degrees if bleed Bedrest first 24 hours, then increase as tolerated. IV fluids; many patients present dehydrated esp. the elderly Swallow assessment – prevent aspiration Diet as tolerated – NG feeds if not taking orally Assess for future needs of enteral feeding. Manage electrolytes : cerebral salt-wasting vs. SIADH Euglycemia (normal level of serum glucose) – sliding scale vs. insulin gtt Fever management or induced hypothermia
  • Important to continuously reassess patients. They are not stable during the firs 24 hours.
  • Confused~ Swallow Evaluation BEFORE they eat anything. Keep NPO until ST sees them and clears their diet.
  • Nicotine in cigarettes act as a vasoconstrictor which further narrows an artery already compromised. Cigarettes lower your HDL (good) cholesterol. Nicotine in cigarettes act as a vasoconstrictor which further narrows an artery already compromised. Cigarettes lower your HDL (good) cholesterol.
  • LDL “bad” cholesterol causes the formation of plaque in arteries. Stroke survivors should aim for LDL cholesterol to be below 70m/dl. Decrease consumption of saturated fats and trans fats. There are many Lipid/Cholesterol altering medications available such as statins and cholesterol absorption inhibitors. Stroke survivors can improve their chances against a second stroke by increasing their physical activity! Choose the stairs instead of the elevator. Get off the couch and go for a walk. The most benefit comes if the activity can be maintained for 15-20 minutes at a time instead of short bursts. Any exercise should be approved by the patient’s physician with regards to intensity and any restrictions. HDL “good” cholesterol prevents atherosclerosis by pulling the cholesterol off the artery wall and preventing the adherence to the artery wall in the first place. HDL levels should be above 40mg/dl Regular aerobic exercise, loss of weight and smoking cessation can help to raise HDL.
  • “One drink” is equivalent to a 12oz. beer, 4 oz. of wine, 1-1/2 oz. of 80-proof spirits or 1 oz. of 100-proof sprits.