Use full for medical and paramedical

1. CEREBROCEREBRO
VASCULARVASCULAR
DISEASEDISEASE
Presented by:Presented by:
Mr. DANIEL VENKATESH .AMr. DANIEL VENKATESH .A
ASSOCIATE PROFESSOR IN NURSINGASSOCIATE PROFESSOR IN NURSING

2. MEANINGMEANING
Results fromResults from
ischemia to a partischemia to a part
of the brain orof the brain or
hemorrhage into thehemorrhage into the
brain that results inbrain that results in
death of brain cellsdeath of brain cells..

3. ISCHEMIC STROKE:ISCHEMIC STROKE:
An ischemic stroke or brain attack is a suddenAn ischemic stroke or brain attack is a sudden
loss of function resulting from disruption of bloodloss of function resulting from disruption of blood
supply to a part of brain.supply to a part of brain.
HEMORRHAGIC STROKE:HEMORRHAGIC STROKE:
It is the bleeding in to the brain tissue,It is the bleeding in to the brain tissue,
ventricles or the subarachnoid space it is mainlyventricles or the subarachnoid space it is mainly
by the rupture of small blood vessels in the brain.by the rupture of small blood vessels in the brain.
INCIDENCE:INCIDENCE:
85% of cerebral disorders are ischemic stroke.85% of cerebral disorders are ischemic stroke.
15% of cerebral disorders are hemorrhagic15% of cerebral disorders are hemorrhagic
stroke.stroke.
Occurs in the people between the ages 50 and 70Occurs in the people between the ages 50 and 70

4. CAUSES:CAUSES:
INTRACEREBRAL BLEED:INTRACEREBRAL BLEED:
It is mainly caused by the rupture of cerebral vessel thatIt is mainly caused by the rupture of cerebral vessel that
bleeds in to the brain tissue.bleeds in to the brain tissue.
HypertensionHypertension
AtherosclerosisAtherosclerosis
Neoplasm'sNeoplasm's
Dural sinus thrombosisDural sinus thrombosis
Congenital angiomasCongenital angiomas
ATRIOVENOUS MALFORMATIONS:ATRIOVENOUS MALFORMATIONS:
Congenital abnormal arteriesCongenital abnormal arteries
Congenital abnormal veinsCongenital abnormal veins

5. INCIDENCE:INCIDENCE:
26,000 cases every new year26,000 cases every new year
4% of cases have asymptomatic4% of cases have asymptomatic
cerebral aneurysm.cerebral aneurysm.
Occurs at ages of 35 and 65 yrs.Occurs at ages of 35 and 65 yrs.
RISK FACTORS:RISK FACTORS:
HypertensionHypertension
SmokingSmoking
TraumaTrauma
Autosomal dominant diseaseAutosomal dominant disease

7. TYPES OF HEMORRHAGICTYPES OF HEMORRHAGIC
STROKE:STROKE:
Intracerebral hemorrhageIntracerebral hemorrhage
Intracranial (cerebral)Intracranial (cerebral)
aneurysmaneurysm
Atriovenous malformationsAtriovenous malformations
Subarachnoid hemorrhageSubarachnoid hemorrhage

8. INTRACRANIAL (CEREBRAL)INTRACRANIAL (CEREBRAL)
ANEURYSM:ANEURYSM:
It is an abnormal dilation of the wallIt is an abnormal dilation of the wall
of the cerebral artery.of the cerebral artery.
TYPES OF CAREBRAL ANEURYSM:TYPES OF CAREBRAL ANEURYSM:
Berry or saccular aneurysmBerry or saccular aneurysm
Giant or fusiform aneurysmGiant or fusiform aneurysm
Mycotic aneurysmMycotic aneurysm
Traumatic aneurysmTraumatic aneurysm

10. Cerebrovascular AccidentCerebrovascular Accident
Thrombotic StrokeThrombotic Stroke

11. THROMBOTIC STROKETHROMBOTIC STROKE
Occlusion of largeOcclusion of large
cerebral vesselcerebral vessel
Older populationOlder population
Sleeping/restingSleeping/resting
Rapid event, butRapid event, but
slow progressionslow progression
(usually reach(usually reach
max deficit in 3max deficit in 3
days)days)

13. Cerebrovascular AccidentCerebrovascular Accident
Embolic StrokeEmbolic Stroke

14. EMBOLIC STROKEEMBOLIC STROKE
EmbolusEmbolus
becomes lodgedbecomes lodged
in vessel andin vessel and
causes occlusioncauses occlusion
Bifurcations areBifurcations are
most commonmost common
sitesite
Sudden onsetSudden onset
with immediatewith immediate
deficitsdeficits

16. Cerebrovascular AccidentCerebrovascular Accident
Hemorrhage StrokeHemorrhage Stroke
Intracerebral HemorrhageIntracerebral Hemorrhage

19. CLASSIFICATION BY SEVERITYCLASSIFICATION BY SEVERITY
Grade I – Minimal Bleed:Grade I – Minimal Bleed:
Minimal headacheMinimal headache
Nuchal rigidityNuchal rigidity
No neurologic deficitNo neurologic deficit
Grade II – Mild Bleed:Grade II – Mild Bleed:
MMild to severe headacheild to severe headache
Nuchal rigidityNuchal rigidity
Minimal neurologic deficitMinimal neurologic deficit

20. Grade III – Moderate Bleed:Grade III – Moderate Bleed:
Drowsy / confusedDrowsy / confused
Severe head acheSevere head ache
Fixed neurologic deficitFixed neurologic deficit
Grade IV – severe Bleed:Grade IV – severe Bleed:
StuporStupor
Hemi paresisHemi paresis
Deep comaDeep coma

21. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Etiological factorsEtiological factors
↓↓
Increase pressure in blood vesselsIncrease pressure in blood vessels
↓↓
Results in rupture and intracranial hemorrhageResults in rupture and intracranial hemorrhage
↓↓
Cerebral edemaCerebral edema
↓↓
Increased intracranial pressureIncreased intracranial pressure
↓↓
Increased pressure over brain tissueIncreased pressure over brain tissue
↓↓
Brain tissue injury and deathBrain tissue injury and death
↓↓
Loss of tissue functionLoss of tissue function

22. CLINICAL FEATURES:CLINICAL FEATURES:
Head acheHead ache
Nuchal rigiditNuchal rigidit
DiplopiaDiplopia
HemiparesisHemiparesis
PhotophobiaPhotophobia
IrritabilityIrritability
Sleep disturbancesSleep disturbances
SeizureSeizure
VomotingVomoting

25. DIAGNOSTIC STUDIES:DIAGNOSTIC STUDIES:
History collectionHistory collection
Physical examinationPhysical examination
DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:
-- C.T scanC.T scan
-- Cerebral angiogramCerebral angiogram
-- Lumbar punctureLumbar puncture

28. CT SCAN ALSO IDENTIFIES INTRACEREBRAL HAEMORRHAGE OR TUMOUR

29. Stroke – investigations (cont’d)Stroke – investigations (cont’d)
Non-invasive investigationNon-invasive investigation
UltrasoundUltrasound – Doppler/Duplex– Doppler/Duplex
scanning:scanning: assesses extra- andassesses extra- and
intracranial vessels.intracranial vessels.

30. Transcranial Doppler
(TCD)
A non invasive
ultrasound technology
used to evaluate blood
flow velocity in the
major basal intracranial
arteries.

31. Transcranial Color Coded Duplex
(TCCD)
TCCD sonography is a newer technique that permits the
real-time visualization of the intracranial vascular
anatomy and blood flow dynamics.

32. Magnetic resonance angiographyMagnetic resonance angiography
(MRA)(MRA) – ‘Time of flight’ or contrast– ‘Time of flight’ or contrast
enhanced techniques are used. Itenhanced techniques are used. It
tends to overestimate the severity oftends to overestimate the severity of
stenosis. When assessing the carotidstenosis. When assessing the carotid
arteries it is best used in combinationarteries it is best used in combination
with Doppler.with Doppler.
Its non-invasive nature makes itIts non-invasive nature makes it
helpful in investigating the intracranialhelpful in investigating the intracranial
Stroke – investigations (cont’d)Stroke – investigations (cont’d)

33. MAGNETIC RESONANCE ANGIOGRAPHY
(MRA)

34. Digital intravenous subtraction angiography (DSADigital intravenous subtraction angiography (DSA))
Stroke – investigations (cont’d)Stroke – investigations (cont’d)

35. MANAGEMENT:MANAGEMENT:
GOALS:GOALS:
Prevent further deterioration in functionPrevent further deterioration in function
Prevent complicationsPrevent complications
Prevent recovery of function.Prevent recovery of function.
PHARMACOLOGICAL MANAGEMENT:PHARMACOLOGICAL MANAGEMENT:
Anti epilepticsAnti epileptics
CorticosteroidsCorticosteroids
Anti hypertensiveAnti hypertensive
Analgesics and SedativesAnalgesics and Sedatives
Anti fibrinolytic therapyAnti fibrinolytic therapy (TpA Thrombolytics Recombinant(TpA Thrombolytics Recombinant
Alteplase (rtPA) Activase, Tissue plasminogen activator)Alteplase (rtPA) Activase, Tissue plasminogen activator)

36. Drug TherapyDrug Therapy

Measures to prevent the development of aMeasures to prevent the development of a
thrombus or embolus for “At Risk” patients:thrombus or embolus for “At Risk” patients:
Antiplatelet AgentsAntiplatelet Agents

AspirinAspirin

PlavixPlavix

CombinationCombination
Oral anticoagulation – CoumadinOral anticoagulation – Coumadin

Treatment of choice for individuals with atrialTreatment of choice for individuals with atrial
fibrillation who have had a TIAfibrillation who have had a TIA
Goals for ManagementGoals for Management

37. Goals for ManagementGoals for Management
Immediate – assess & stabilizeImmediate – assess & stabilize

ABCs, VSABCs, VS

Neurologic screeningNeurologic screening

Oxygen if hypoxicOxygen if hypoxic

IV accessIV access

Check glucoseCheck glucose

Activate stroke team –Activate stroke team – CODE GREENCODE GREEN

12-lead EKG12-lead EKG
Immediate Neuro AssessmentImmediate Neuro Assessment
Establish symptom onsetEstablish symptom onset

Review hxReview hx

Stroke ScaleStroke Scale

Facial droop; arm drift; abnormal speechFacial droop; arm drift; abnormal speech

39. CT Scan – No hemorrhage:CT Scan – No hemorrhage:

Consider Fibrinolytic therapyConsider Fibrinolytic therapy
Check for exclusionsCheck for exclusions
tPAtPA

No anticoagulants or antiplatelet therapy for 24 hoursNo anticoagulants or antiplatelet therapy for 24 hours

If not a candidate: Antiplatelet TherapyIf not a candidate: Antiplatelet Therapy
CT Scan – Hemorrhage:CT Scan – Hemorrhage:

Neurosurgery?Neurosurgery?

If no surgery: Stroke UnitIf no surgery: Stroke Unit
Monitor BP and treat HypertensionMonitor BP and treat Hypertension
Monitor Neuro statusMonitor Neuro status
Monitor blood glucose and treat as neededMonitor blood glucose and treat as needed
Supportive therapySupportive therapy
Goals for ManagementGoals for Management

40. COMPLICATIONS:COMPLICATIONS:
VasospasmVasospasm
Re bleedingRe bleeding
Unresolved cerebral edemaUnresolved cerebral edema
HydrocephalusHydrocephalus

41. SURGICAL MANAGEMENTSURGICAL MANAGEMENTISCHEMICISCHEMIC
EndovascularEndovascular

CarotidCarotid
endarectomyendarectomy

Merci clotMerci clot
removalremoval

TransluminalTransluminal
angioplastyangioplasty
http://youtu.be/P2TNz-TniIAhttp://youtu.be/P2TNz-TniIA
HEMORRHAGICHEMORRHAGIC
DecompressionDecompression

CraniotomyCraniotomy

CraniectomyCraniectomy

ICP monitorICP monitor
placementplacement

42. SURGICALSURGICAL
MANAGEMENTMANAGEMENT
FOR ISCHEMICFOR ISCHEMIC
STROKESTROKE

43. CAROTID ENDARTERECTOMYCAROTID ENDARTERECTOMY

44. MERCI CLOT REMOVALMERCI CLOT REMOVAL

45. SURGICALSURGICAL
MANAGEMENTMANAGEMENT
FORFOR
HEMORRHAGICHEMORRHAGIC
STROKESTROKE

46. CRANIOTOMYCRANIOTOMY

47. CEREBROVASCULAR ACCIDENTCEREBROVASCULAR ACCIDENT
Nursing GoalsNursing Goals
Maintain stable or improved LOCMaintain stable or improved LOC
Attain maximum physical functioningAttain maximum physical functioning
Attain maximum self-care activities & skillsAttain maximum self-care activities & skills
Maintain stable body functionsMaintain stable body functions
Maximize communication abilitiesMaximize communication abilities
Maintain adequate nutritionMaintain adequate nutrition
Avoid complications of strokeAvoid complications of stroke
Maintain effective personal & family copingMaintain effective personal & family coping

48. Warning Signs of StrokeWarning Signs of Stroke
Sudden weakness, paralysis, or numbnessSudden weakness, paralysis, or numbness
of the face, arm, or leg, especially on oneof the face, arm, or leg, especially on one
side of the bodyside of the body
Sudden dimness or loss of vision in one orSudden dimness or loss of vision in one or
both eyesboth eyes
Sudden loss of speech, confusion, orSudden loss of speech, confusion, or
difficulty speaking or understanding speechdifficulty speaking or understanding speech
Unexplained sudden dizziness,Unexplained sudden dizziness,
unsteadiness, loss of balance, orunsteadiness, loss of balance, or
coordinationcoordination
Sudden severe headacheSudden severe headache
CEREBROVASCULAR ACCIDENTCEREBROVASCULAR ACCIDENT

49. CEREBROVASCULAR ACCIDENTCEREBROVASCULAR ACCIDENT
Acute PhaseAcute Phase
AssessAssess:: Frequently to assess CVA evolutionFrequently to assess CVA evolution
NeuroNeuro — Glascow Coma Scale -- mental status, LOC,— Glascow Coma Scale -- mental status, LOC,
pupillary response, extremity movement, strength,pupillary response, extremity movement, strength,
sensation; ICP; Communication—speaking &sensation; ICP; Communication—speaking &
understanding; sensory-perceptual alterationsunderstanding; sensory-perceptual alterations
CVCV– cardiac monitoring; VS, PO, hemodynamic– cardiac monitoring; VS, PO, hemodynamic
monitoring;monitoring;
RespResp — airway/air exchange/aspiration;— airway/air exchange/aspiration;
GIGI — swallowing—gag reflex; bowel sounds; bowel— swallowing—gag reflex; bowel sounds; bowel
movement regularitymovement regularity
GUGU — urinary continence— urinary continence
IntegumentaryIntegumentary — skin integrity, hygiene— skin integrity, hygiene
CopingCoping – individual and family– individual and family

50. CEREBROVASCULAR ACCIDENTCEREBROVASCULAR ACCIDENT
ACUTE PHASEACUTE PHASE
Nsg ActionNsg Action::

Supportive CareSupportive Care
Respiratory – spans from intubation to breathing onRespiratory – spans from intubation to breathing on
ownown
Musculoskeletal -- Positioning – side-to-side; HOBMusculoskeletal -- Positioning – side-to-side; HOB
elevated; PROM exercise; splints; shoes/footboardelevated; PROM exercise; splints; shoes/footboard
GI – enteral feedings initiallyGI – enteral feedings initially
GU – foley catheterGU – foley catheter
Skin – preventive careSkin – preventive care
Meds: anti plateletMeds: anti platelet

51. CEREBROVASCULAR ACCIDENTCEREBROVASCULAR ACCIDENT
Acute PhaseAcute Phase
Patient Education:Patient Education:

Clear explanations for all care/treatmentsClear explanations for all care/treatments

Focus on improvements—regainedFocus on improvements—regained
abilitiesabilities

Include familyInclude family

52. CEREBROVASCULAR ACCIDENTCEREBROVASCULAR ACCIDENT
REHABILITATIONREHABILITATION
Assess: Swallowing; Communication;Assess: Swallowing; Communication;
Complications; motor and sensoryComplications; motor and sensory
functionfunction
Nsg Action: Coordinate resources:Nsg Action: Coordinate resources:

Speech Therapy—assess swallowingSpeech Therapy—assess swallowing

Physical Therapy—ambulation/strengtheningPhysical Therapy—ambulation/strengthening

Bowel/BladderBowel/Bladder

Appropriate self-help resourcesAppropriate self-help resources

53. TH
AN
K
YOU