2. Stroke/ Cerebrovascular Accident/ Brain
Attack
• It is the onset and persistence of
neurologic dysfunction lasting longer
than 24 hours and resulting from the
disruption of blood supply to the brain.
3. Classification of Strokes
I. Ischemic Stroke
Partial or complete occlusion of a cerebral
blood flow to an area of the brain due to:
a. Transient Ischemic Attack(TIA)
- brief period of cerebral ischemia that
causes neurologic deficits
b. Thrombus (most common)
-due to an arteriosclerotic plaque in a
cerebral artery, usually at bifurcation of
large arteries
4. Classification of Strokes
I. Ischemic Stroke
c. Embolus
-a moving clot of cardiac origin or from a
carotid artery that travels quickly to the
brain and lodges in a small artery.
5.
6. Types of Ischemic Stroke
1. Large artery thrombotic stroke
-caused by atherosclerotic plaques in the
large blood vessels of the brain;
occlusion is at the site of atherosclerosis
2. Small penetrating artery thrombotic stroke
- also called as lacunar strokes because
of the cavity that is created after the
death of infarcted brain tissue
8. Types of Ischemic Stroke
3. Cardiogenic embolic stroke
- emboli originate from the heart and
circulate to the cerebral vasculature,
most commonly the left middle cerebral
artery
4. Cryptogenic stroke -no known cause
5. Strokes from other causes
- illicit drug use, coagulopathies, migraine,
spontaneous dissection of the carotid or
vertebral arteries
12. Pathophysiology
Obstruction of the blood vessel
↓
Disruption of cerebral blood flow
↓
Initiation of ischemic cascade
↓
Membrane depolarization of the
cell wall
↓
Increase intracellular release of
calcium glutamate
↓
Damage of pathways
↓
Destruction of the cell membrane
Generation of free radicals
Vasoconstriction
13. Classification of Strokes
II. Hemorrhagic Stroke
•Leakage of blood from a blood vessel and
hemorrhage into the brain tissue causing
edema, compression of the brain tissue
and spasm of adjacent blood vessels.
•Primarily caused by intracranial or
subarachnoid hemorrhage
•Hemorrhage commonly occurs suddenly
while a person is active.
14. Classification of Strokes
II. Hemorrhagic Stroke
Causal mechanisms:
a.Increased pressure due to hypertension
b.Head trauma
c.Deterioration of vessel wall
d.Congenital weakening of blood vessel
15. Pathophysiology
Increase blood volume and flow
within a weakened cerebral
arterial wall or capillary bed
↓
Increase in BP
↓
Dilatation of arteries and veins
↓
Rupture
↓
Bleeding
↓
Subarachnoid/ Intracerebral
hemorrhage
↓
Increase in ICP
↓
Neurovascular/ Neurologic
damage
16.
17. Clinical Manifestations
*Vary depending on the vessel affected and the
cerebral territories it perfuse. Symptoms
usually are multiple.
1. Headache- not always present
2. Changes in the LOC
3. Signs and symptoms related to vascular
territory:
a. Numbness (paresthesia), weakness
(paresis), or loss of motor mobility (plegia)
on one side of the body.
18. Clinical Manifestations
b. Difficulty swallowing (dysphagia)
c. Aphasia – loss of speech (expressive,
receptive, visual, global)
d. Visual difficulties of inattention or
neglect (lack of acknowledgement of one
side of the sensory field), loss of half of the
visual field (hemianopsia), double vision,
photophobia
e. Acalculia (inability to perform
mathematical calculations)
19. Clinical Manifestations
f. Agnosia (Loss of the ability to interpret
sensory stimuli)
e. Altered cognitive abilities and
psychological affect
f. Self-care deficits
20. Hemorrhagic Stoke:
1. Severe headache
2. Increased intracranial pressure
3. Neurological deficits similar to ischemic
stroke
4. Vomiting
5. Early sudden change in LOC
6. Focal seizures due to brainstem
involvement
21. AVM:
1. Sudden, severe headache
2. Loss of consciousness
3. Pain and rigidity of the back and neck
(nuchal rigidity) and spine due to
meningeal irritation
4. Visual disturbances
5. Tinnitus
6. Dizziness
7. Hemiparesis
22.
23.
24.
25. Stroke Deficits Related to Vascular Territory
Cerebral Artery Brain Area Involved Signs and symptoms
Anterior Cerebral Infarction of the middle
aspect of one frontal
lobe if lesion is distal to
communicating artery;
bilateral frontal
infarction if flow in other
anterior cerebral artery
is inadequate
1. Paralysis of the contralateral
foot or leg
2. Impaired gait
3. Paralysis of the contralateral
arm
4. Contralateral sensory loss
over toes foot and leg
5. Problems making decisions or
performing acts voluntarily
6. Lack of spontaneity
7. Easily distracted
8. Slowness of thought
9. Aphasia depends on
hemisphere involved
10.Urinary incontinence
11.Cognitive and affective
disorders
26. Stroke Deficits Related to Vascular Territory
Cerebral Artery Brain Area Involved Signs and symptoms
Middle Cerebral Massive infarction of
most of the lateral
hemisphere and deeper
structures of the frontal,
parietal and temporal
lobes; internal capsule;
basal ganglia
1. Contralateral hemiplegia of
the face and arm
2. Contralateral sensory
impairment
3. Aphasia
4. Homonymous hemiplegia
5. Altered consciousness
(confusion to coma)
6. Inability to turn eyes toward
paralyzed side
7. Denial of paralized side or
limb (hemiattention)
8. Possible acalculia (inability to
perform mathematical
calculations), alexia (visual
aphasia), finger agnosia and
left to right confusion.
9. Vasomotor paresis and
instability
27. Stroke Deficits Related to Vascular Territory
Cerebral Artery Brain Area Involved Signs and symptoms
Posterior
Cerebral
Occipital Lobe; anterior
and medial portion of
temporal lobe
Thalamus involvement
Cerebral peduncle
involvment
1. Homonymous hemianopsia
and other visual defects such
as :
a.color blindness
b.Loss of central vision
c.Visual hallucinations
2. Memory deficits
3. Perseveration (repeated
performance of same verbal
or motor response
1. Loss of all sensory modalities
2. Spontaneous pain
3. Intentional tremor
4. Mild hemiparesis
5. Aphasia
Oculomotor nerve palsy with
contralateral hemiplegia
28. Stroke Deficits Related to Vascular Territory
Cerebral Artery Brain Area Involved Signs and symptoms
Basilar and
vertebral
Cerebellum and brain
stem
1. Diplopia
2. Dystaxia (lack of muscular
coordination resulting in shaky
limb movements and
unsteady gait.
3. Vertigo
4. Dysphagia
5. Dysphonia
29. Assessment and Diagnostic
Findings
1. Complete physical and neurological
examination
a. Airway patency
b. Cardiovascular status
c. Gross neurologic deficits
2. Identify or rule out TIA
3. CT scan
4. Carotid UTZ
5. MRI or CT angiogram
6. Cerebral angiography
31. Management:
Acute Treatment
1. Support vital functions.
2. Reperfusion and hemodilution with colloids
and volume expanders
3. Thrombolytic therapy (ischemic stroke)
Recombinant tissue plasminogen (tPA)
0.9 mg/kg
a. intravenously within 3 hours of
onset of symptoms
b. transarterially within 6 hours of
onset of symptoms
32. Management:
Acute Treatment
4. Manage increase in ICP
5. Manage increase in blood pressure. Maintain
BP within prescribed parameters and limit
hypertensive fluctuations. Keep systolic BP less
than 200 mmHg to reduce vessel wall stressors
a. Management of systemic HPN with
nitroprusside (Nipride) or alternative IV
antihypertensive agents
b. Vasopressor agents to maintain systolic
BP within prescribed range.
33. Management:
Acute Treatment
6. Diuretic treatment
7. Calcium channel blockers, nimodipine
(Nimotop)
Subsequent Treatment (Ischemic stroke)
1. Anticoagulation after hemorrhage is ruled
out.
2. Anti-platelet agents such as ticlodipine
(Ticlid), Dipyridamole/ aspirin (Aggrenox) and
clopidogrel (Plavix) or aspirin
34. Management:
Subsequent Treatment
3. Surgical Prevention
Ischemic Stroke
Carotid Endarterectomy or removal of an
atherosclerotic plaque or thrombus from the
carotid artery
Hemorrhagic stroke
Clipping of the aneurysm to prevent re-
bleeding
Removal of blood from the baseal cisterns
around major cerebral arteries
35. Management:
Subsequent Treatment
4. Antispasmodic agents for spastic paralysis
5. Rehabilitation Program
a. Physical therapy
b. Occupational therapy
c. Speech therapy
d. Counseling
6. Selective Serotonin reuptake inhibitors
36. Nursing Intervention
• Preventing falls and other injuries
- Maintain bed rest during the acute phase with
HOB slightly elevated and side rails in place
- Administer O2 as ordered to maximize cerebral
oxygenation.
- Frequently assess respiratory status, VS, heart
rate and rhythm and urine output to maintain
and support vital functions.
- Allay confusion and agitation with calm
reassurance and presence.
37. • Implement BP and aneurysm precautions
(HS)
-Provide a non stimulating environment
-Bed rest; head of bed 15-30⁰
-Prevent straining , valsalva maneuver,
forceful sneezing, pushing self in bed,
acute flexion or rotation of the head and
neck, cigarette smoking and any activity
requiring exertion
38. Nursing Intervention
• Preventing complications of Immobility
- Maintain functional positions of extremities
- Apply splints and braces as indicated
- Exercise the affected extremities passively
through ROM.
- Teach patient to use unaffected extremity to
move the affected one.
- Assist with ambulation as needed with help of
physical therapy as indicated.
39. Nursing Intervention
• Optimizing cognitive abilities
– Be aware of the patient’s cognitive alterations
and adjust interaction and environment
accordingly.
– Participate in cognitive retraining program
– Focus on patient’s strengths and give positive
feedback
– Be aware that depression is common and
therapy should include psychotherapy and
pharmacological agents.
40. Nursing Intervention
• Facilitating Communication
- Speak slowly, using visual cues and gestures;
be consistent and repeat as necessary.
- Speak directly to the patient while facing him
- Give plenty of time for response and reinforce
attempts as well as correct responses
- Minimize distractions
- Use alternative methods of communication
other than verbal, such as written words, gesture
or pictures.
41. Nursing Intervention
• Promoting adequate oral intake
- Evaluate swallowing function of patient.
- demonstrate safe and functional
swallowing mechanisms before initiation of
oral diet.
- Encourage small, frequent meals and
allow plenty of time to chew and swallow.
Remind patient to chew on the unaffected
side.
42. Nursing Intervention
• Promoting adequate oral intake
- Encourage to drink small sips from a
straw with chin tucked to the chest
- Inspect mouth for food collection and
pocketing before entry of each new bolus
of food.
- Encourage frequent oral hygiene
43. Nursing Intervention
• Attaining bladder control
- Insert indwelling bladder catheterization
during the acute phase
- Establish regular voiding schedule.
- Assist with standing or sitting to void
44. Nursing Intervention
• Patient education and health maintenance
- Teach the patient and family to adapt to
home environment for safety and ease of
use
- Instruct the patient of the need for rest
periods throughout the day.
- Encourage consistency in the
environment without distraction
- Assist family to obtain self-help aids for
the patient
