Cerwbrovascular accident

1. SALALE UNIVERSITY
COLLEGAE OF HEALTH SCIENCE
DEPARTMENT OF ADULT HEALTH NURSING
Seminar presentation on :Cerebrovascular Accident &TIA.
Presented To : Mr. Bikila T (BSC MSC Ass’t Professor)
Presented by: Shambel Debel—ID—190/15
09- oct-2023
Fiche Ethiopia
11/4/2023 Stroke & TIA 1

2. Presentation outline
• Introduction
• Objective
• Etiology
• Pathophysiology
• Epidemiology
• Clinical manifestations
• Diagnostic Studies
• Management
• Prevention
• Reference
11/4/2023 Stroke & TIA 2

3. Objective
• At the end of this presentation, the participants
will be able to:
• To define cerebrovascular accident and TIA.
 Identify etiology/Risk factors of stroke and TIA.
 Explain pathophysiology of stroke and TIA.
 Explain clinical manifestation of stroke & TIA.
 Identify diagnostic studies.
 Identify the management and prevention of stroke
& TIA.
11/4/2023 Stroke & TIA 3

4. INTRODUCTION
• Stroke is the 5th leading cause of death in the US, with
one person dying every 4 minutes .
For black people, stroke is the 3rd leading cause of death.
• It is the second leading cause of death in the world.
• Approximately 800,000 people have a stroke each year;
about one every 40 seconds.
• Strokes occur due to problems with the blood supply to
the brain, either the blood supply is blocked or a blood
• vessel within the brain ruptures, causing brain tissue to
die.
• A stroke is a medical emergency, and treatment must be
sought as quickly as possible.
11/4/2023 Stroke & TIA 4

5. Introduction cont.…
• Transient ischemic attack :is a medical emergency.
• It is defined as a transient episode of neurologic
dysfunction due to the focal brain, spinal cord, or retinal
ischemia, without acute infarction or tissue injury. The
definition of a TIA has moved from time-based to
tissue-based.
• A TIA typically lasts less than an hour, more often
minutes. TIA can be considered as a serious warning for
an impending ischemic stroke; the risk is highest in the
first 48 hours following a transient ischemic attack.
11/4/2023 Stroke & TIA 5

6. Stroke
11/4/2023 Stroke & TIA 6

7. Transient ischemic attacks/TIA
11/4/2023 Stroke & TIA 7

8. 11/4/2023 Stroke & TIA 8

9. Definition
• A stroke is defined as the clinical syndrome of
rapid onset of cerebral deficit lasting more than
24 hours or leading to death with no apparent
cause other than a vascular one.
• A stroke is a rapid loss of brain function due to
the disturbance in the blood supply to brain.
A stroke happens when blood flow to a part of the
brain stops and it is sometimes called a brain
attack.
11/4/2023 Stroke & TIA 9

10. Epidemiology
• Stroke is prevalent all over the World wide.
• It is third commonest cause of death in developed
world next to CAD ( coronary artery disease) and
cancer.
• It is a leading cause of disability.
• Approximately 500,000 people experience a new
stroke every year.
• Approximately 160,000 die of a stroke each year.
• The prevalence and incidence of stroke is also on
the rise in developing countries.
11/4/2023 Stroke & TIA 10

11. Cause/Risk factors Stroke cont.…
Non Modifiable
• Age
• Gender( male> female)
• Race(Asian>european)
• Heredity
• Previous Vascular
• event.eg: MI, peripheral
• embolism
• High fibrinogen
Modifiable
• High blood pressure
• Diabetes mellitus
• Hyperlipidemia
• Smoking
• Excess alcohol
consumption
• Oral contraceptives
• Social deprivation
• Obesity, sedentary
lifestyle
11/4/2023 Stroke & TIA 11

12. Pathophysiology of stroke
• Brain requires constant supply of glucose & oxygen,
delivered by blood.
• Brain receives 15% of resting output & accounts for
20% of total body oxygen consumption.
• Cerebral blood flow is maintained via auto regulation.
Thus the brain is highly aerobic tissue where oxygen
is limiting factor.
• Blood flow
• If zero leads to death of brain tissue within 4-10 mins
• <16-18ml/100g tissue/min infarction with in an
hour.
• <20ml/100gm tissue/min ischemia without
infarction unless prolonged for several hours or
day.
11/4/2023 Stroke & TIA 12

13. Types of stroke
11/4/2023 Stroke & TIA 13

14. Types of stroke
11/4/2023 Stroke & TIA 14

15. Type of stroke cont.…
A .Ischemic stroke - (85%), cerebrovascular
accident (CVA), in which there is vascular occlusion
and significant hypo perfusion occur.
• It is termed “brain attack”
• It is a sudden loss of function resulting from
disruption of the blood supply to a part of the
brain.
11/4/2023 Stroke & TIA 15

16. Ischemic stroke…
• Ischemic stroke are subdivided in to different
types according to their cause:
1.Large artery thrombosis (20%), are due to
atherosclerotic plaques in the large blood vessels of
the brain resulting from narrowing of cerebral
arteries.
2.Small penetrating artery thrombosis (25%)
affect one or more vessels
11/4/2023 Stroke & TIA 16

17. Ischemic stroke…
3.Ardiogenic embolic stroke (20%)
• Are associated with cardiac dysrhythmias,
usually atrial fibrillation.
• Emboli originate from the heart and circulate to
the cerebral vasculature.
• Most commonly in the left middle cerebral artery.
• Embolic strokes may be prevented by the use of
anticoagulation therapy in patients with atrial
fibrillation.
11/4/2023 Stroke & TIA 17

18. Ischemic stroke…
4. Cryptogenic (30%)
• Strokes, which have no known cause.
5. Others (5%)
• Other strokes, can be from - cocaine use,
coagulopathies, migraine, and spontaneous
dissection of the carotid or vertebral arteries.
11/4/2023 Stroke & TIA 18

19. Etiology of ischemic stroke
• Lacunar stroke
• Large vessel
thrombosis
• Hypercoagulable
disorders
Artery to artery
• Carotid bifurcation
• Aortic arch
• Cardio embolic
Atrial fibrillation
• Myocardial infarction
• Mural thrombus
• Bacterial endocarditic
• Mitral stenosis
• Paradoxical embolus
11/4/2023 Stroke & TIA 19

20. Thrombotic Stroke
• Atherosclerosis:- is the most common
pathology leading to thrombotic occlusion of
blood vessels
• Lacunar stroke
• Accounts for 20% of all strokes
• Results from occlusion of small deep penetrating
• arteries of the brain
• Thrombosis leads to small infarcts known as
lacunes
• Clinically manifested as lacunar syndromes
11/4/2023 Stroke & TIA 20

21. Embolic Stroke
Cardio embolic stroke
• Embolus from the heart gets lodged in intracranial
vessels
• MCA most commonly affected
• Atrial fibrillation is the most common cause
• Others: MI, prosthetic valves, rheumatic heart
disease
11/4/2023 Stroke & TIA 21

22. Embolic Stroke
Artery to artery embolism
• Thrombus formed on atherosclerotic plaques
gets embolized to intracranial vessels.
• Carotid bifurcation atherosclerosis is the most
• Common source Others: aortic arch, vertebral
arteries etc.
11/4/2023 Stroke & TIA 22

23. Stroke cant…
B. Hemorrhagic (15%)
• In which there is extravasation of blood into the
brain.
• Patients generally have more severe deficits and
a longer recovery time compared to those with
ischemic stroke
• Hemorrhagic strokes are caused by bleeding
into the brain tissue, the ventricles, or the
subarachnoid space.
11/4/2023 Stroke & TIA 23

24. Hemorrhagic stroke cont.…
• Hemorrhagic stroke
• Two types
1.Intracerebral hemorrhage
• From a spontaneous rupture of small vessels,
accounts for approximately 80% of
hemorrhagic strokes and is primarily caused
by uncontrolled hypertension.
11/4/2023 Stroke & TIA 24

25. Hemorrhagic stroke cont.…
2.Subarachnoid hemorrhage
It is associated with arteriovenous malformations
(AVMs), from ruptured intracranial aneurysm, or
certain medications e.g. anticoagulants and
amphetamine.
Higher mortality rates when compared to ischemic
stroke
11/4/2023 Stroke & TIA 25

26. Hemorrhagic stroke cont.…
11/4/2023 Stroke & TIA 26

27. Transient ischemic attacks (TIA)
 Definition:-A transient episode of neurological
dysfunction caused by Focal brain, spinal chord or
retinal ischemia without actual tissue infarction.
• Stroke symptoms and signs that resolve within 1
hour .
• It’s a clinical consequence of a temporary
interruption of blood supply to a focal part of the
brain with consequent disruption of function.
• TIA gives a major warning for development of
stroke 5% within 48 hours ,50% in 5 years .
11/4/2023 Stroke & TIA 27

28. 11/4/2023 Stroke & TIA 28

29. Epidemiology
• TIA incidence in a population is difficult to estimate
due to other mimicking disorders. Internationally,
the probability of a first TIA is around 0.42 per
1000 population in developed countries.
• TIA incidence in the United States could be around
half a million per year, and estimates are about 1.1
per 1000 in the United States population.
• The estimated overall prevalence of TIA among
adults in the United States is approximately 2%
TIAs occur in about 150,000 patients per year in
the United Kingdom. It has been shown that
previous stroke history increases the prevalence
of TIA.
11/4/2023 Stroke & TIA 29

30. Cause/Risk factors(TIA)
• Atherosclerosis of extracranial carotid,vertebral or
intracranial vessels.
• Embolic sources - Valvular disease, ventricular
thrombus, or thrombus formation from atrial
fibrillation, aortic arch disease, paradoxical
embolism via a patent foramen ovale or atrial-
septal defect.
• Hypercoagulable states –polycythemia
vera,associated with cancer or genetic
hypercoagulable conditions.
11/4/2023 Stroke & TIA 30

31. Pathophysiology
• A TIA is characterized by a temporary reduction
of blood flow in a neurovascular distribution as a
result of partial or total occlusion –typically from
a thromboembolic event or stenosis of vessel.
• Clinical manifestation would depend on the
cerebral territory involved .
11/4/2023 Stroke & TIA 31

32. Cause/Risk factors(TIA)…
• HTN(86%)
• DM(24%)
• Tobacco smoking(23%)
• Previous stroke(19%)
• Previous TIA(15%)
• cardiac arrhythmias(9%)
• dyslipidemia,obesity,oral contraceptive
pills/hormone replacement therapy, carotid artery
stenosis
alcoholism.
11/4/2023 Stroke & TIA 32

33. Cont…
11/4/2023 Stroke & TIA 33

34. Signs and symptoms(TIA)
• Signs and symptoms of a TIA begin suddenly,
main symptoms can be recognized with the word
F-A-S-T:FACE ARM SPEECH TIME
• FACE-facial droop/asymmetry
• ARMS-arm drift, arm weakness, numbness .
• Speech-slurring of speech
11/4/2023 Stroke & TIA 34

35. C/m Stroke cont.…
Clinical Manifestations
• Stroke can cause a wide variety of neurologic
deficits, depending on the location of the lesion and
the size of the area of inadequate perfusion.
• Numbness or weakness of the face, arm, or leg,
especially on one side of the body
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Visual disturbances
• Sudden severe headache
• Motor, sensory, cranial nerve, cognitive, and other
functions may be disrupted.
11/4/2023 Stroke & TIA 35

36. C/m Stroke cont.…
Motor loss
• Loss of voluntary control over motor movements.
• The most common motor dysfunction is
Hemiplegia due to a lesion of the opposite side of
the brain.
• Hemiparesis, or weakness of one side of the body.
• In the early stage of stroke
• Flaccid paralysis
• Loss of or decrease in the deep tendon reflexes.
11/4/2023 Stroke & TIA 36

37. C/m Stroke cont.…
Communication loss
• Other brain functions affected by stroke are
language and communication.
• Dysarthria:difficulty in speaking caused by
paralysis of the muscles responsible for
producing speech
• Dysphasia or aphasia: defective speech or
loss of speech
• Apraxia: inability to perform a previously learned
action, as may be seen when a patient picks up a
fork and attempts to comb his hair
11/4/2023 Stroke & TIA 37

38. C/m Stroke cont.…
Perceptual disturbances
• Perception is the ability to interpret sensation.
• Stroke can result in visual-perceptual
dysfunctions, disturbances in visual-spatial
relations, and sensory loss.
• Visual-perceptual dysfunctions are due to
disturbances of the primary sensory pathways
between the eye and visual cortex.
• Homonymous hemianopsia (loss of half of the
visual field) may occur and may be temporary or
permanent.
11/4/2023 Stroke & TIA 38

39. C/m Stroke cont.…
Sensory loss
• Form of slight impairment of touch or may be
more severe, with loss of proprioception (ability
to perceive the position and motion of body
parts.
• As well as difficulty in interpreting visual, tactile,
and auditory stimuli.
11/4/2023 Stroke & TIA 39

40. C/m Stroke cont.…
Bladder Dysfunction
• After a stroke the patient may have transient
urinary incontinence due to confusion, inability
to communicate his needs, and inability to use
the urinal/bedpan
• Occasionally after a stroke the bladder becomes
atonic with impaired sensation in response to
bladder filling.
11/4/2023 Stroke & TIA 40

41. C/m Stroke cont.…
Cognitive impairment and psychological effects
 If damage has occurred to the frontal lobe,
learning capacity, memory, or other higher cortical
intellectual functions may be impaired.
 Such dysfunction may be reflected in a limited
attention span, difficulties in comprehension,
forgetfulness, and a lack of motivation.
 Depression is common
 Other psychological problems are common and
are Manifested by emotional lability, hostility,
frustration, and lack of cooperation.
11/4/2023 Stroke & TIA 41

42. Stroke and TIA…
Assessment and Diagnostic Findings
Any patient with neurologic deficits needs a careful
history and a complete physical and neurologic
examination.
• Initial assessment will focus on airway patency, which
may be compromised by loss of gag or cough reflexes
and altered respiratory pattern; cardiovascular status
(including blood pressure, cardiac rhythm and rate,
carotid bruit), and gross neurologic losses
11/4/2023 Stroke & TIA 42

43. CONT…
 To diagnose a TIA, the symptoms must have
resolved within 1 hr.
 Look for possible sources of emboli eg
arrhythmias (especially AF), heart murmurs,
carotid bruits, MI (mural thrombus).
 A finger stick blood glucose for hypoglycaemia
 Complete blood count
 Serum electrolyte levels
 Coagulation studies
 12-lead electrocardiogram (ECG) with rhythm
strip
11/4/2023 Stroke & TIA 43

44. History
• Look for risk factors for stroke.
• Looking for other medical conditions associated
with stroke such as hypertension, diabetes,
smoking and use of drugs like OCP may suggest
the diagnosis.
11/4/2023 Stroke & TIA 44

45. Stroke cont.…
Physical Examination
 Give clue to the type of stroke the patient is
suffering from.
• Absent/reduced peripheral pulses
suggest atherosclerosis or embolism.
• Presence of neck bruit suggests extra
cranial occlusion of carotid arteries.
• Cardiac abnormalities: such as atrial
fibrillation, murmurs or cardiac
enlargement may suggest embolic stroke,
the embolus originating from the heart.
11/4/2023 Stroke & TIA 45

46. Stroke cont.…
Ophthalmoscopic examination:
• Papille edam or retinal hemorrhage may suggest
subarachnoid hemorrhage or intracranial
pressure.
• Fever raises concern for infectious etiologies.
• Increased blood pressure for hypertension.
Confirmation of Diagnosis
• Imaging Studies (CT or MRI): are the most
important .
CT determine if the event is ischemic or
hemorrhagic.
MRI is more sensitive than CT for early diagnosis of
brain infarction.
11/4/2023 Stroke & TIA 46

47. Stroke cont.…
Other tests
• Lumbar Puncture
• Angiography: to identify the exact location
and the specific artery blocked.
• Echocardiography: to look for cardiac sources
of embolization.
• FBS, Lipid profile: to look for diabetes and
hyperlipidemia are risk factor
11/4/2023 Stroke & TIA 47

48. DDX Stroke and TIA
 Craniocerebral / cervical trauma
Meningitis/encephalitis Intracranial
mass
 Tumor
 Subdural hematoma
 Seizure with persistent neurological signs
 Migraine with persistent neurological signs
Metabolic
 Hyperglycemia
 Hypoglycemia
 Post-cardiac arrest ischemia
 Drug/narcotic overdose
11/4/2023 Stroke & TIA 48

49. Diagnostic modalities of brain
Non invasive
• CT Scan
• MRI Scan
• MR Angiography
• Doppler Ultrasound
• EEG
• PET
• SPECT
Invasive
• Lumbar Puncture
• Contrast Angiography
(Cerebral
• Arteriography)
• CTAngiography
11/4/2023 Stroke & TIA 49

50. stroke cont.…
Management and prevention
• The best way to prevent a stroke is to address
the underlying causes.
• Avoid illicit drugs
• Eat a diet rich in fruit and vegetables and low in
cholesterol and saturated fat
11/4/2023 Stroke & TIA 50

51. Stroke cont.…
• Exercise regularly
• Keep blood pressure under control
• Keep diabetes under control
• Maintain a healthy weight
• Moderate alcohol consumption (or quit drinking)
Goal of treatment:
• Interruption of further brain damage.
• Management of complication
11/4/2023 Stroke & TIA 51

52. Stroke cont.…
General Measures
• Admit the patients where close follow up can be
given.
• Continue follow up and maintenance of vital
functions.
• Airway and ventilation.
• Controlling of blood pressure.
• Controlling body temperature.
• Fluid administration/hydration
11/4/2023 Stroke & TIA 52

53. Stroke cont.…
• Adequate oxygenation of blood to the brain is
necessary to minimize cerebral damage.
• Blood pressure and cardiac output must be
maintained to sustain cerebral blood flow, and
hydration intravenous fluids.
• Oxygen therapy, if necessary, should be given at
an adequate perfusion pressure.
• The patient is placed in a lateral or semi-prone
position with the head of the bed slightly elevated
to lower cerebral venous pressure.
11/4/2023 Stroke & TIA 53

54. Stroke cont.…
Management of specific Etiologies
1.Atherosclerotic Stroke (Thrombotic Stroke).
 Thrombolytic therapy
• They are used to treat ischemic stroke by
dissolving the blood clot that is blocking blood
flow to the brain.
• Medications such as t-PA (plasminogen
activator), to patients who present with in 3 hrs
of onset of stroke helps to lyses the thrombus
and restore perfusion to the affected brain.
11/4/2023 Stroke & TIA 54

55. Stroke cont.…
 Anticoagulants
• Use of Heparin or Warfarin .
• Low dose heparin can give for prevention of
thromboembolism.
 Anti-platelet aggregation agents
• Aspirin reduces the incidence of stroke.
• It may not help to resolve the already formed
thrombus, but ASA prevents recurrence of
stroke.
11/4/2023 Stroke & TIA 55

56. Stroke cont.…
2.Embolic Stroke: (Cardiogenic embolus)
• Anticoagulation is indicated to prevent
recurrent embolic stroke.
• Heparin should be initiated when the
acute phase of stroke is over.
• Warfarin is used for chronic
anticoagulation.
11/4/2023 Stroke & TIA 56

57. Stroke cont.…
3. Intracerebral hemorrhage
• Continue supportive measures.
• Control very high blood pressure.
• Surgical consultation is indicated for removing
cerebelar hematoma, as it may compress vital
centers in the brainstem.
• If patient is hypertensive
• treat for hypertension
• Diuretics to reduce cerebral edema.
11/4/2023 Stroke & TIA 57

58. Stroke cont.…
4. Subarachnoid Hemorrhage
 Supportive measures include bed rest,
sedatives, analgesic.
 Control of hypertension
 Nifidipin (calcium channel blocker) is given to
prevent neurologic deterioration due to
vasopasm.
Surgical therapy: aneurysms are treated
surgically.
11/4/2023 Stroke & TIA 58

59. Stroke cont…
Prevention of further stroke
 Control of hypertension.
 Control blood sugar in diabetics.
Cessation of smoking.
physical activity and weight reduction
11/4/2023 Stroke & TIA 59

60. Management of Transient Ischemic Attack (Tia)
MEDICAL MANAGEMENT
• If diffuse atherosclerotic disease or poor
operative candidates.
Stop smoking
• Concurrent medical problems to be addressed:
Emboli from heart and other parts of
cardiovascular system
a. anti coagulants: Heparin IV, Warfarin oral
b. anti platelet drugs: Aspirin oral, Ticlopidine
Diabetes, Hypertension, Hyperlipidemia
11/4/2023 Stroke & TIA 60

61. Management of (TIA) – cont..
SURGICAL MANAGEMENT
• Carotid and cerebral arteriography
 All above can be done only if there is relatively little
atherosclerosis elsewhere in cerebrovascular system.
11/4/2023 Stroke & TIA 61

62. Nursing diagnosis
• Altered cerebral tissue perfusion
– Monitor respiratory and airway patency
• Suction only as needed
• Lateral low Fowler’s position ( HOB 30 to
 cerebral edema, head in neutral position
– improves venous drainage)
• If risk for hemorrhage or IICP, no coughing,
deep breathing
• If no risk of hemorrhage, cough and deep
breathe
• Oxygen as ordered
11/4/2023 Stroke & TIA 62

63. Nursing interventions
• Maintain a patent airway
• Encourage passive range of motion every 2 hr to
the affected extremities and active range of
motion every 2 hr to the unaffected extremities to
prevent DVT
• Avoid risk of falls
• Monitor for changes in the client’s level of
consciousness (ICP sign)
• Elevate the client’s head to reduce intracranial
pressure (ICP) and to
promote venous drainage.
11/4/2023 Stroke & TIA 63

64. Nursing interventions cont…
• Elevate the affected extremities to promote
venous return and to reduce
swelling.
• Avoid extreme flexion or extension, maintain the
head in the midline
neutral position, and elevate the head of the bed
to 30°
• Maintain a non-stimulating environment
• Assist with communication skills if the client’s
speech is impaired
• Assist pt to achieve self care, assist in safe
feeding
• Maintain skin integrity
• Improving family coping through health teaching
11/4/2023 Stroke & TIA 64

65. 11/4/2023 Stroke & TIA 65

66. Reference
 Stroke: Causes, Symptoms, Diagnosis and Treatment.
 Availableathttp://www.medicalnewstoday.com/articles/7624.p
hp?page=3.
 https://www.cdc.gov/ National stroke association Available
at: www.stroke.org.
 http://www.who.int/topics/cerebrovascular_accident/en/
Stroke health center. Available at: www.webmd.com/stroke
 The global stroke burden by Sarah Song MD,MPH available
at https://worldneurologyonline.com/article/theglobal-stroke-
burden
11/4/2023 Stroke & TIA 66

67. THANK YOU!
11/4/2023 Stroke & TIA 67