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  1. 1. Cerebrovascular Accident CVA/STROKE 1
  2. 2. Cerebrovascular Accident is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. Results from ischemia to a part of the brain or hemorrhage into the brain that results in death of brain cells.  Third most common cause of death  #1 leading cause of disability  25% with initial stroke die within 1 year  50-75% will be functionally independent  25% will live with permanent disability 2
  3. 3. Cerebrovascular Accident Risk FactorsNonmodifiable: Age – Occurrence doubles each decade >55 years Race – African Americans Heredity – family history, prior transient ischemic attack, or prior stroke increases risk 3
  4. 4. Cerebrovascular Accident Risk FactorsControllable Risks High blood pressure Diabetes Cigarette smoking High blood cholesterol Obesity Heart Disease Atrial fibrillation Oral contraceptive use Physical inactivity Asymptomatic carotid stenosis Hypercoagulability 4
  5. 5. Cerebrovascular Accident Anatomy of Cerebral Circulation Blood Supply  Anterior: Carotid Arteries – middle & anterior cerebral arteries frontal, parietal, temporal lobes; basal ganglion; part of the diencephalon (thalamus & hypothalamus)  Posterior: Vertebral Arteries – basilar artery Mid and lower temporary & occipital lobes, cerebellum, brainstem, & part of the diencephalon  Circle of Willis – connects the anterior & posterior cerebral circulation 5
  6. 6. Cerebrovascular Accident Anatomy of Cerebral CirculationBlood Supply 20% of cardiac output—750-1000ml/min >30 second interruption– neurologic metabolism is altered; metabolism stops in 2 minutes; brain cell death < 5 mins. 6
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  8. 8. Cerebrovascular Accident PathophysiologyAtherosclerosis: major cause of CVA Thrombus formation & emboli development Abnormal filtration of lipids in the intimal layer of the arterial wall Plaque develops at locations of increased turbulence of blood – Bifurcations Calcified plaques rupture or fissure Platelets & fibrin adhere to the plaque Narrowing or blockage of an artery by thrombus or emboli 8
  9. 9. Cerebrovascular Accident Transient Ischemic Attack Temporary focal loss of neurologic function Caused by ischemia of one of the vascular territories of the brain  Microemboli with temporary blockage of blood flow Lasts less than 24 hrs – often less than 15 mins Most resolve within 3 hours Warning sign of progressive cerebrovascular disease 9
  10. 10. Cerebrovascular Accident ClassificationsBased on underlying pathophysiologic findings 10
  11. 11. Cerebrovascular Accident Classifications Ischemic Stroke Thrombotic Emboli Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage Aneurysm Arterio venous malformation 11
  12. 12. Cerebrovascular Accident Classifications Ischemic Stroke—inadequate blood flow to the brain from partial or complete occlusions of an artery--85% of all strokes – Extent of a stroke depends on: • Rapidity of onset • Size of the lesion • Presence of collateral circulation – Symptoms may progress in the first 72 hours as infarction & cerebral edema increaseTypes of Ischemic Stroke: Thrombotic Stroke Embolic Stroke 12
  13. 13. Cerebrovascular Accident Ischemic – Thrombotic Stroke Lumen of the blood vessels narrow – then becomes occluded – infarctionAssociated with HTN and Diabetes Mellitus >60% of strokes 50% are preceded by TIA Lacunar Stroke: development of cavity in place of infarcted brain tissue – results in considerable deficits – motor hemiplegia, contralateral loss of sensation or motor ability 13
  14. 14. Cerebrovascular Accident Thrombotic Stroke 14
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  16. 16. Cerebrovascular AccidentCommon Sites of Atherosclerosis 16
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  18. 18. Cerebrovascular Accident Ischemic – Embolic StrokeEmbolus lodges in and occludes a cerebral arteryResults in infarction & cerebral edema of the area supplied by the vesselSecond most common cause of stroke – 24%Emboli originate mainly from endocardial layer of the heart – atrial fibrillation, MI, infective endocarditis, valvular prosthesesRapid occurrence with severe symptoms – body does not have time to develop collateral circulationAny age groupRecurrence common if underlying cause not treated 18
  19. 19. Cerebrovascular Accident Embolic Stroke 19
  20. 20. Cerebrovascular Accident Hemorrhagic StrokeHemorrhagic Stroke 15% of all strokes Result from bleeding into the brain tissue itself Intracerebral Subarachnoid 20
  21. 21. Cerebrovascular Accident Hemorrhage Stroke Intracerebral Hemorrhage Rupture of a vessel Hypertension – most important cause Others: vascular malformations, coagulation disorders, anticoagulation, trauma, brain tumor, ruptured aneurysms Sudden onset of symptoms with progression Neurological deficits, headache, nausea, vomiting, decreased LOC, and hypertension Prognosis: poor – 50% die within weeks 20% functionally independent at 6 months 21
  22. 22. Cerebrovascular Accident Hemorrhage StrokeIntracerebral Hemorrhage 22
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  24. 24. Cerebrovascular Accident Hemorrhagic-SubarachnoidHemorrhagic Stroke–Subarachnoid Hemorrhage Intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain 24
  25. 25. Cerebrovascular Accident Hemorrhagic-SubarachnoidCommonly caused by rupture of cerebral aneurysm (congenital or acquired) Saccular or berry – few to 20-30 mm in size Majority occur in the Circle of WillisOther causes: Arteriovenous malformation (AVM), trauma, illicit drug abuseIncidence: 6-16/100,000Increases with age and more common in women 25
  26. 26. Cerebrovascular Accident Hemorrhagic-Subarachnoid Cerebral AneurysmWarning Symptoms: sudden onset of a severe headache – “worst headache of one’s life”Change of LOC, Neurological deficits, nausea, vomiting, seizures, stiff neck 26
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  28. 28. Hemorrhagic-Subarachnoid Cerebral AneurysmSurgical Treatment: Clipping the aneurysm – prevents rebleed Coiling – platinum coil inserted into the lumen of the aneurysm to occlude the sac Postop: Vasospasm prevention – Calcium Channel Blockers 28
  29. 29. Hemorrhagic-SubarachnoidCerebral Aneurysm – Surgical Tx 29
  30. 30. Hemorrhagic-SubarachnoidCerebral Aneurysm – Coiling 30
  31. 31. Clinical manifestationsNeurologic deficits Depending on –• Location of the lesion (which vessel are obstructed )• The size of the area of inadequate perfusion• The amount of collateral blood flow 31
  32. 32. Motor lossStroke is a disease of upper motor neuron and results in loss of voluntary control over motor movements- Upper motor neuron decussate- most common motor dysfunction is hemiplegia due to lesion of the opposite side of the brain- Hemiparesis also another sign- 32
  33. 33. CommunicationAphasia/Dysphasia:-defect or loss of speech - Receptive Aphasia :- sounds of speech nor its meaning can be understood – spoken & written - Expressive Aphasia :- difficulty in speaking and writingDysarthria: Affects the mechanics of speech due to muscle control disturbances – pronunciation, and phonation 33
  34. 34. Perceptual disturbance• Visual perceptual dysfunction -due to disturbances of the primary sensory pathways between the eye and visual cortexHomonymous Hemianopia:-loss of half of the visual field - may be temporary or permanent - the affected side of the vision corresponds to the paralyzed side of the body - pts head turns away from the affected side of his body 34
  35. 35. Disturbance in Visual spatial r/ship• Perceiving relationship of two or more objects in spatial areas• Frequently seen in patients with left hemiplegia• Pt may not able to dress him/herself b/se of his/her ability to match his clothing to his body parts 35
  36. 36. Sensory losses• Loss of proprioception :-inability to perceive position and motion of body parts• Difficulty in interpreting visual ,tactile,and auditory stimuli 36
  37. 37. AffectDifficulty controlling emotionsExaggerated or unpredictable emotional responseDepression / feelings regarding changed body image and loss of function 37
  38. 38. Intellectual FunctionMemory and judgment Left-brain stroke: cautious in making judgments Right-brain stroke: impulsive & moves quickly to decisionsDifficulties in learning new skills 38
  39. 39. EliminationMost problems occur initially and are temporaryOne hemisphere stroke: prognosis is excellent for normal bladder functionBowel elimination: motor control not a problem – constipation associated with immobility, weak abdominal muscles, dehydration, diminished response to the defecation reflex 39
  40. 40. Cerebrovascular Accident Clinical ManifestationsRight Brain – Left Brain Damage 40
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  43. 43. Homonymous Hemianopia 43
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  45. 45. Cerebrovascular Accident Treatment Goals Prevention Drug Therapy Surgical Therapy Rehabilitation 45
  46. 46. Cerebrovascular Accident Treatment GoalsPrevention – Health Maintenance Focus: Healthy diet Weight control Regular exercise No smoking Limit alcohol consumption Route health assessment Control of risk factors 46
  47. 47. Cerebrovascular Accident Diagnostic StudiesDone to confirm CVA and identify cause PE: Neuro Assessment Carotid doppler studies (ultrasound study) CT – primary – identifies size, location, differentiates between ischemic and hemorrhagic MRI – greater specificity than CT May not be able to be used on all patients (metal, claustrophobia) Angiography: gold standard for imaging carotid arteries 47
  48. 48. Cerebrovascular Accident Treatment Goals Drug Therapy – Thrombotic CVA – to reestablish blood flow through a blocked artery Thrombolytic Drugs: tPA (tissue plasminogen activator)  produce localized fibrinolysis by binding to the fibrin in the thrombi  Plasminogen is converted to plasmin (fibrinolysin)  Enzymatic action digests fibrin & fibrinogen  Results is clot lysis Administered within 3 hours of symptoms of ischemic CVA  Confirmed DX with CT  Patient anticoagulated ASA, Calcium Channel Blockers 48
  49. 49. Cerebrovascular Accident Treatment GoalsDrug Therapy Measures to prevent the development of a thrombus or embolus for “At Risk” patients: Antiplatelet Agents Aspirin Plavix Combination Oral anticoagulation – Coumadin Treatment of choice for individuals with atrial fibrillation who have had a TIA 49
  50. 50. CVA - Treatment GoalsSurgical Treatment Carotid endarterectomy – preventive – > 100,000/year removal of atheromatous lesions Clipping, wrapping, coiling Aneurysm Evacuation of aneurysm-induced hematomas larger than 3 cm. Treatment of AV Malformations 50
  51. 51. Carotid Endarterectomy 51
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  53. 53. Cerebrovascular Accident Nursing Diagnoses Ineffective tissue perfusion r/t decreased cerebrovascular blood flow Ineffective airway clearance Impaired physical mobility Impaired verbal communication Impaired swallowing Unilateral neglect r/t visual field cut & sensory loss Impaired urinary elimination Situational low self-esteem r/t actual or perceived loss of function 53
  54. 54. Cerebrovascular Accident Nursing GoalsMaintain stable or improved LOCAttain maximum physical functioningAttain maximum self-care activities & skillsMaintain stable body functionsMaximize communication abilitiesMaintain adequate nutritionAvoid complications of strokeMaintain effective personal & family coping 54
  55. 55. Cerebrovascular Accident Warning Signs of StrokeSudden weakness, paralysis, or numbness of the face, arm, or leg, especially on one side of the bodySudden dimness or loss of vision in one or both eyesSudden loss of speech, confusion, or difficulty speaking or understanding speechUnexplained sudden dizziness, unsteadiness, loss of balance, or coordinationSudden severe headache 55
  56. 56. Cerebrovascular Accident Acute PhaseNsg Action: Supportive Care Respiratory – spans from intubation to breathing on own Musculoskeletal -- Positioning – side-to-side; GU – Foley catheter Skin – preventive care Meds: anti platelet 56
  57. 57. Cerebrovascular Accident Acute PhasePatient Education: Clear explanations for all care/treatments Focus on improvements—regained abilities Include family 57
  58. 58. Cerebrovascular Accident RehabilitationAssess: Swallowing; Communication; Complications; motor and sensory functionNsg Action: Coordinate resources: Speech Therapy assess swallowing Physical Therapy—ambulation/strengthening Bowel/Bladder Appropriate self-help resources 58
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