K:STROKE CENTERStaff Learning OpportunitieseLearnMOD1 (rev. 01.18.01
STROKE: The Brain Matters
Prevalence and incidence:
From 1970s to early 1990s, non-
institutionalized stroke survivors increased
from 1.5 million to 2.4 million
On average, every 45 seconds someone in the
U.S. has a stroke
Each year 700,000 people experience a new or
Blacks have almost twice the risk of first-ever
stroke compared with whites
Impact of stroke
Stroke accounted for about one of every 15
deaths in the U.S. in 2003
Stroke ranks No. 3 among all causes of death
8-12% of ischemic strokes and 37-38% of
hemorrhagic strokes result in death within 30
Top cause of disability
Estimated Direct and Indirect Costs of
Major Cardiovascular Diseases and Stroke
United States: 2006
Source: Heart Disease and Stroke Statistics – 2006 Update
What is Stroke?
Clinical diagnosis supported by testing
Abrupt onset of neurologic deficit
attributable to a focal vascular cause
Sudden loss of blood, with subsequent loss
of nutrients and oxygen to a part of the brain,
causing cell death
Ischemic vs. Hemorrhagic
80% of all strokes
Ischemic strokes occur if blood flow is blocked locally in an
artery supplying the brain or if the entire circulation fails so that
all organs, including the brain, are inadequately perfused
What might block a brain artery?
1. Pathology such as atherosclerotic plaque in the vessel's wall
that narrows or even obliterates its lumen or produces complete
collapse of the wall
2. A "plug" in its lumen formed by material carried in the blood
3. Abnormally high pressure in brain tissue surrounding the
vessel that compresses its wall to the point of squeezing shut its
most common and occurs
in arteries narrowed by
occurs when a wandering
clot or other particle forms
away from the brain
(usually the heart or aorta)
and this clot occludes an
artery leading to the brain
20% of all strokes
Half involve rupture of either aneurysms
which initially bleed into the subarachnoid
space or of arteriovenous malformations
which are often located within the brain and
therefore tend to bleed into the brain itself.
Both of these pathologies are thought to be the
consequence of developmental abnormalities
and are characterized by thinned vascular walls
Caused by rupture of the walls of small penetrating
arteries serving deep structures, with bleeding
directly into the brain and its ventricles
These vessels are at particular risk because of their
thin muscular walls and narrow lumens. It is
thought that the cumulative effects of untreated
hypertension and atherosclerosis or other kinds of
pathologic changes weaken their walls and put them
at special risk for rupture
Small arteries supplying the superficial regions of
the cerebral hemispheres may develop deposits of
an abnormal protein called amyloid in the
In some cases, this material can weaken the walls
of these vessels to the extent that they rupture and
cause hemorrhages in the superficial regions of the
Unlike the intracerebral hemorrhages involving
midline penetrating vessels, superficial lobar
hemorrhages can occur in individuals who have had
normal blood pressure throughout
Transient Ischemic Attack (TIA)
Symptoms and causes similar to stroke
Important RISK FACTOR; about 15% of all
strokes are heralded by a TIA
TIAs are produced by transient blockage of the
cerebral or retinal circulation. Typical duration
of symptoms is 5-15 minutes
By definition, neurologic deficits that resolve in
Evaluation parallels that of stroke
Risk factors for stroke after TIA
Age over 60 years
Symptom duration more than 10 minutes
Residual weakness or speech disturbance
N Eng J Med 4/17/03
Different parts of the brain:
Cerebrum ~ The cerebrum (supratentorial or front of brain) is
composed of the right and left hemispheres. Functions of the
cerebrum include: initiation of movement, coordination of movement,
temperature, touch, vision, hearing, judgment, reasoning, problem
solving, emotions, and learning.
Brainstem ~ The brainstem (midline or middle of brain) includes the
midbrain, the pons, and the medulla. Functions of this area include:
movement of the eyes and mouth, relaying sensory messages (hot,
pain, loud, etc.), hunger, respirations, consciousness, cardiac function,
body temperature, involuntary muscle movements, sneezing,
coughing, vomiting, and swallowing.
Cerebellum ~ The cerebellum (infratentorial or back of brain) is
located at the back of the head. Its function is to coordinate voluntary
muscle movements and to maintain posture, balance, and equilibrium.
More specific areas of the brain:
Pons ~ A deep part of the brain, located in the brainstem, the pons contains many of
the control areas for eye and face movements.
Medulla ~ The lowest part of the brainstem, the medulla is the most vital part of the
entire brain and contains important control centers for the heart and lungs.
Frontal lobe ~ The largest section of the brain located in the front of the head, the
frontal lobe is involved in personality characteristics and movement.
Parietal lobe ~ The middle part of the brain, the parietal lobe helps a person to
identify objects and understand spatial relationships (where one's body is compared
to objects around the person). The parietal lobe is also involved in interpreting pain
and touch in the body.
Occipital lobe ~ The occipital lobe is the back part of the brain that is involved with
Temporal lobe ~ The sides of the brain, these temporal lobes are involved in
memory, speech, and sense of smell.
o Sudden numbness or weakness of face, arm or leg
especially on one side of the body
o Sudden confusion, trouble speaking or
o Sudden trouble seeing in one or both eyes
o Sudden trouble walking, dizziness, loss of balance
o Sudden severe headache with no known cause
Neurologic symptoms of occluded
vessels will vary depending on location
Vessels typically effected and an
overview of possible symptoms
Middle cerebral artery
Anterior cerebral artery
Posterior cerebral artery
Aphasia, visual field defects, hemi
paresis, hemiplegia, hemi sensory
loss, inattention, apraxia.
Diplopia, dysarthria, ataxia, poor
motor coordination, vertigo,
Personality changes, confusion,
weakness usually> distally,
Cortical blindness, dyslexia, visual
field defects if occipital.
Altered level of consciousness,
American Heart Association’s
7 “D’s” of Stroke Care
Detection, early recognition of the signs and symptoms and determination of onset time.
If the patient awakened with signs and symptoms of a stroke, the onset time is
considered the last time he was seen awake without them.
Dispatch, rapidly getting the patient emergency medical care.
Delivery, transporting him to the nearest stroke center or a hospital capable of following
the latest stroke guidelines.
Door, rapid triage in the ED.
Data, documenting or collecting information about the patient's history, lab work,
imaging studies, examinations, physical assessments, and time of onset of signs and
symptoms. Needs to undergo a noncontrast computed tomography (CT) scan of the brain
within 25 minutes of arrival at the ED, and it must be interpreted within 45 minutes of
arrival to determine if an acute ischemic stroke occurred.
Decision, answering the inclusion and exclusion criteria for t-PA therapy and reviewing
treatment options with the patient and family.
Drug, starting t-PA treatment within 3 hours of onset of symptoms if all conditions are
met; Nursing care at the door.
Lab work: Complete blood cell count, glucose
and electrolyte levels, renal and liver function
studies, prothrombin and partial thromboplastin
times, and cardiac biomarkers
CT of brain (w/angiography IF indicated and
does not delay administration of t-PA)
CT of brain with angiography
Timing is critical!!
Three (3) hour window of time to receive
acute treatment for ischemic stroke.
ED Ischemic stroke pathway:
t-PA (Tissue Plasminogen Activator)
Inclusion / Exclusion Criteria
Clinical diagnosis of stroke
Age 18 or older
Time of stroke onset (i.e. last time pt witnessed to be well) < 3 hours
BP Systolic <= 185, diastolic <= 110 (can receive 1-3 doses of BP agent for control)
Pro time <= 15 seconds or INR <= 1.7
Platelet count >= 100,000
Blood Glucose => 50 and <= 400 mg/dl
Minor stroke or rapidly resolving stroke
Seizure at onset of stroke
Heparin treatment during the past 48 hours with an elevated PTT
Evidence of acute myocardial infarction
Exclusion Criteria (Relative Contraindications):
History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm
Major surgical procedures within 14 days
Stroke or serious head injury within 3 months
Gastrointestinal or urinary bleeding within last 21 days
Lactation or Pregnancy within 30 days
Modified from NINDS criteria
t-PA dose and administration
Tissue Plasminogen Activator (t-PA)
Drug class = Fibrinolytic used to treat acute ischemic
stroke. Clot-specific binding to fibrin-bound plasminogen
allowing conversion to plasmin, which digests the fibrin.
Onset of action occurs in 60-90 minutes.
LOADING dose = 0.09 mg/kg IV push over 1 minute (dose
not to exceed 9 mg)
INFUSION dose = 0.81 mg/kg IV infusion over 1 hour (dose
not to exceed 81 mg)
Post-thrombolytic order set
Key issues: ASA, heparin, Coumadin
contraindicated up to 24 hrs. after t-PA
NPO until swallow evaluated
Assess for changes in neuro status that may
indicate post t-PA complication of bleeding
Assess any other abnormal bleeding
Stroke Patient Placement
Patient placement is planned with use of
designated stroke unit beds unless other
factors determine otherwise
After t-PA, patients are monitored in CICU
18-24 hrs (or SCU). If stable, they are then
transferred to P3CD (R4, if tele needed)
If you think someone may be having a stroke, act F.A.S.T. and do this
FACE Ask the person to smile.
Does one side of the face droop?
ARMS Ask the person to raise both arms.
Does one arm drift downward?
SPEECH Ask the person to repeat a simple sentence.
Are the words slurred? Can he/she repeat the sentence correctly?
TIME If the person shows any of these symptoms, time is
Call 911 or get to the hospital fast. Brain cells are dying.
TIME LOST IS BRAIN LOST!