Cerebrovascular Accidents CME 2007

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Cerebrovascular Accidents CME 2007

  1. 1. Cerebral Vascular Accident
  2. 2. Types of CVA’s <ul><li>Ischemic </li></ul><ul><li>Subarachnoid hemorrhage </li></ul><ul><li>Intracerebral Hemorrhage </li></ul>
  3. 3. Ischemic CVA <ul><li>Thrombotic – clot forms in diseased or damaged artery </li></ul><ul><li>Embolic- clot travels from distant location, often the heart with atrial fibrillation </li></ul>
  4. 4. Brain Ischemia <ul><li>Blood flow to a portion of brain is interrupted and can result in tissue death. </li></ul><ul><li>Area of damage often localized with specific pattern of symptoms. </li></ul><ul><li>Cerebral edema can result from iscemia and increase ICP. </li></ul>
  5. 5. Intracerebral Hemorrhage <ul><li>Diseased blood vessel bursts and bleeding occurs into brain tissue </li></ul><ul><li>Increasing pressure causes damage to surrounding tissue </li></ul>
  6. 6. Subarachnoid Hemorrhage <ul><li>“ Berry” aneurysm bursts, bleeding occurs between brain surface and cranium </li></ul><ul><li>Rapid build up of pressure can cause unconsciousness or death </li></ul>
  7. 7. Risk Factors <ul><li>Atrial fibrillation </li></ul><ul><li>Anticoagulants </li></ul><ul><li>Hypertension </li></ul><ul><li>High cholesterol </li></ul><ul><li>Diabetes </li></ul><ul><li>Alcohol abuse </li></ul><ul><li>Smoking </li></ul><ul><li>Race </li></ul><ul><li>Family history </li></ul>
  8. 8. Signs & Symptoms It can be difficult to clinically determine the type of stroke.
  9. 10. Signs and symptoms can include <ul><li>Confusion </li></ul><ul><li>Loss of consciousness </li></ul><ul><li>Aphasia </li></ul><ul><li>Dizziness or loss of balance </li></ul><ul><li>Signs are related to part of brain that is affected and can vary with each patient </li></ul>
  10. 11. Signs can be unilateral <ul><li>Weakness or paralysis </li></ul><ul><li>Numbness </li></ul><ul><li>Unequal pupils </li></ul><ul><li>Facial droop </li></ul>
  11. 12. Eyes often provide clues <ul><li>Unequal pupils </li></ul><ul><li>Impaired vision </li></ul><ul><li>Extraocular movements </li></ul><ul><li>Pinpoint pupils </li></ul>
  12. 13. Signs that may indicate a bleed <ul><li>Headache </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Progressive onset </li></ul><ul><li>Hypertension </li></ul><ul><li>Pt takes anticoagulants </li></ul><ul><li>History of recent stroke </li></ul>
  13. 14. Signs that favor a clot <ul><li>Sudden onset </li></ul><ul><li>Complaints localized to one limb </li></ul><ul><li>History of Atrial Fibrillation </li></ul><ul><li>History of TIA </li></ul>
  14. 15. It is important to recognize the signs of a stroke And to note the time of their onset.
  15. 16. TIME IS CRITICAL
  16. 17. It is important to know the time of onset of stroke symptoms because <ul><li>If treatment for embolic strokes using a thrombolytic (clot breaking) medication is appropriate it must be started within three hours. </li></ul><ul><li>The sooner these are given, the better. </li></ul><ul><li>Patients should be transported to a Stroke Center immediately. </li></ul>
  17. 20. Other diagnostic tools <ul><li>MRI – can provide more detailed image </li></ul><ul><li>Cerebral angiography-used to image the blood vessels of the brain </li></ul>
  18. 21. Don’t forget the “basics” <ul><li>Airway </li></ul><ul><li>Breathing </li></ul><ul><li>Circulation (blood pressure and pulse) </li></ul><ul><li>Blood glucose (hypoglycemia can often appear like a stroke) </li></ul><ul><li>Drugs and alcohol can too. </li></ul>
  19. 22. CPP=MAP - ICP If the intercranial pressure is high a high blood pressure is necessary to perfuse the brain.
  20. 23. History and physical key points <ul><li>carotid bruits </li></ul><ul><li>Sensation and motor function in each extremity (grasp, flexor, extensor) </li></ul><ul><li>Pupils and ocular movement </li></ul><ul><li>Gait (if possible) </li></ul><ul><li>Mental status </li></ul><ul><li>EKG </li></ul><ul><li>SpO2 </li></ul><ul><li>ABG’s </li></ul><ul><li>ICP monitor </li></ul><ul><li>Glucose </li></ul><ul><li>I/O </li></ul><ul><li>Labs: INR, CBC, Plt </li></ul>
  21. 24. Treatment considerations <ul><li>Dilantin </li></ul><ul><li>Vitamin K / FFP </li></ul><ul><li>Blood pressure control </li></ul><ul><li>Heparin </li></ul><ul><li>Aspirin? </li></ul>
  22. 25. Diagnostics <ul><li>The cause of a CVA is usually determined by head CT </li></ul><ul><li>Note the positive “arrow” sign </li></ul><ul><li>Hypoperfused region is dark </li></ul>
  23. 26. Thrombolytics <ul><li>Treatment for embolic strokes </li></ul><ul><li>tPA tissue plasminogen activator dissolves fibrin clots </li></ul><ul><li>Has potential to prevent permanent brain iscemia </li></ul><ul><li>Can cause catastrophic hemorrhage in some patients </li></ul>
  24. 27. Thrombolytic check list <ul><li>  </li></ul><ul><li>INCLUSION criteria (must all be YES) </li></ul><ul><li>Age 18 years or older ___ </li></ul><ul><li>Time of onset well established to be less than 3 hours ___ </li></ul><ul><li>Clinical diagnosis of ischemic stroke causing a ___ </li></ul><ul><li>measurable neurological deficit </li></ul><ul><li>CT without hemorrhage ___ </li></ul><ul><li>Risks/benefits: Discussed and documented in chart ___ </li></ul><ul><li>  </li></ul><ul><li>EXCLUSION criteria (must all be NO) </li></ul><ul><li>SBP>185 or DBP>110 despite simple measures ___ </li></ul><ul><li>Symptoms rapidly improving or minor symptoms (NIHSS = 0) ___ </li></ul><ul><li>Coma or severe obtundation ___ </li></ul><ul><li>Seizure at onset ___ </li></ul><ul><li>Symptoms of subarachnoid hemorrhage ___ </li></ul><ul><li>Stroke or head trauma within 3 months ___ </li></ul><ul><li>Major surgery within 14 days ___ </li></ul><ul><li>History of intracranial hemorrhage ___ </li></ul><ul><li>GI hemorrhage or urinary tract hemorrhage within 21 days ___ </li></ul><ul><li>Arterial puncture at a noncompressible site or LP within 7 days ___ </li></ul><ul><li>Recent MI complicated by pericarditis ___ </li></ul><ul><li>Patients receiving heparin within 48hrs and with an elevated PTT ___ </li></ul><ul><li>PT greater than 15 (»INR > 1.7) ___ </li></ul><ul><li>Platelet count < 100,000 ___ </li></ul><ul><li>Glucose below 50 or above 400 ___ </li></ul><ul><li>Pregnant ( Note : menstruation is NOT a contraindication) ___ </li></ul>
  25. 29. Treatment for hemorrhagic strokes <ul><li>Surgically clipping a berry aneurysm </li></ul>
  26. 30. Coil placed in aneurysm
  27. 31. <ul><li>Stent placed in </li></ul><ul><li>Vertebral artery. </li></ul>

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