This document provides information about cerebrovascular accidents (strokes), including: 1. Strokes occur when blood supply to the brain is disrupted, causing brain cells to die from lack of oxygen and nutrients. 2. There are two main types of strokes - ischemic (lack of blood flow) and hemorrhagic (bleeding in the brain). 3. Signs and symptoms of strokes vary depending on the area of the brain affected but may include weakness, confusion, vision problems, and headaches.

1. Cerebrovascular Accident (CVA) “Stroke” Ma. Tosca Cybil A. Torres, RN

2. Review of Anatomy Brain -the brain is the most powerful organ, yet weighs only about three pounds. It has a texture similar to firm jelly. It has three main parts: The cerebrum fills up most of the skull. It is involved in remembering, problem solving, thinking, and feeling. It also controls movement. The cerebellum sits at the back of the head, under the cerebrum. It controls coordination and balance. The brain stem sits beneath the cerebrum in front of the cerebellum. It connects the brain to the spinal cord and controls automatic functions such as breathing, digestion, heart rate and blood pressure.

3. the brain is nourished by one of the body's richest networks of blood vessels. With each heartbeat, arteries carry about 20 to 25 percent of blood to the brain, where billions of cells use about 20 percent of the oxygen and fuel the blood carries. When thinking hard, the brain may use up to 50 percent of the fuel and oxygen. The whole vessel network includes veins and capillaries in addition to arteries.

4. the brain’s wrinkled surface is a specialized outer layer of the cerebrum called the cortex . Scientists have “mapped” the cortex by identifying areas strongly linked to certain functions. Specific regions of the cortex: Interpret sensations from the body, and sights, sounds and smells from the outside world. Generate thoughts, solve problems and make plans Forms and stores memories Control voluntary movements.

5. The left half controls the right side of the body. The right half controls the body’s left The brain is divided into right and left halves.

6. The real work of the brain goes on in individual cells. An adult brain contains about 100 billion nerve cells, or neurons, with branches that connect at more than 100 trillion points. Scientists call this dense, branching network a "neuron forest." Signals traveling through the neuron forest form the basis of memories, thoughts, and feelings.

7. Signals that form memories and thoughts move through an individual nerve cell as a tiny electrical charge. Nerve cells connect to one another at synapses. When a charge reaches a synapse, it may trigger release of tiny bursts of chemicals called neurotransmitters . The neurotransmitters travel across the synapse, carrying signals to other cells.

8. Cerebrovascular Accident (CVA) Other terms: “stroke”, “brain attack”, “acute ischemic cerebrovascular syndrome” occurs when blood supply to part of the brain is disrupted, causing brain cells to die. When blood flow to the brain is impaired, oxygen and glucose cannot be delivered to the brain. Blood flow can be compromised by a variety of mechanisms. a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". -WHO

9. Mechanisms that compromise the blood flow to the brain

10. Blockage of an artery Arteriosclerosis-hardening of the arteries leading to the brain Atherosclerosis-arteries become narrow because of plaque or cholesterol Embolism to the brain from the heart.

11. Rupture of an artery (hemorrhage) Cerebral hemorrhage (bleeding within the brain substance). The most common reason to have bleeding within the brain is uncontrolled high blood pressure. Other situations include aneurysms that leak or rupture or arteriovenous malformations (AVM) in which there is an abnormal collection of blood vessels that are fragile and can bleed.

12. Classification of Stroke

13. Ischemic Stroke

14. In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction and necrosis of the brain tissue in that area. There are four reasons why this might happen: thrombosis (obstruction of a blood vessel by a blood clot forming locally) embolism (idem due to an embolus from elsewhere in the body, see below), systemic hypoperfusion (general decrease in blood supply, e.g. in shock) venous thrombosis. Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin). Ischemic Stroke

15. Types of Ischemic Stroke

16. Thrombotic Stroke In thrombotic stroke, a thrombus (blood clot) usually forms around atherosclerotic plaques. Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower. A thrombus itself (even if non-occluding) can lead to an embolic stroke. if the thrombus breaks off, at which point it is called an "embolus". Thrombotic stroke can be divided into two types depending on the type of vessel the thrombus is formed on: Large vessel disease Small vessel disease Sickle cell anemia, which can cause blood cells to clump up and block blood vessels, can also lead to stroke. Stroke is the second leading killer of people under 20 who suffer from sickle-cell anemia.

17. Embolic stroke Embolic stroke refers to the blockage of an artery by an embolus, a traveling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g. from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis). Because an embolus arises from elsewhere, local therapy only solves the problem temporarily. Thus, the source of the embolus must be identified. Because the embolic blockage is sudden in onset, symptoms usually are maximal at start. Also, symptoms may be transient as the embolus is partially resorbed and moves to a different location or dissipates altogether. Emboli most commonly arise from the heart (especially in atrial fibrillation) but may originate from elsewhere in the arterial tree. In paradoxical embolism, a deep vein thrombosis embolises through an atrial or ventricular septal defect in the heart into the brain.

18. Systemic Hypoperfusion Systemic hypoperfusion is the reduction of blood flow to all parts of the body. It is most commonly due to cardiac pump failure from cardiac arrest or arrhythmias, or from reduced cardiac output as a result of myocardial infarction, pulmonary embolism, pericardial effusion, or bleeding. Hypoxemia (low blood oxygen content) may precipitate the hypoperfusion. Because the reduction in blood flow is global, all parts of the brain may be affected, especially "watershed" areas - border zone regions supplied by the major cerebral arteries. Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur. This phenomenon is also referred to as "last meadow" to point to the fact that in irrigation the last meadow receives the least amount of water.

19. Venous Thrombosis Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke.

20. Transient Ischemic Attack (TIA) is paramount in the diagnosis of atherothrombotic stroke TIA is also a predictor of myocardial infarction TIA presentation depends on what blood vessels is involved (any blood vessel may be involved) TIAs usually last several minutes to hours (<10 minutes) Several attacks (1 to 100 attacks!!) may occur before the final stroke Final stroke may follow the TIA in a matter of hours or less frequently weeks to months!

21. Hemorrhagic Stroke

22. Hemorrhagic Stroke

23. Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system).

24. The main types of extra-axial hemorrhage: epidural hematoma (bleeding between the dura mater and the skull) subdural hematoma (in the subdural space) subarachnoid hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g. headache, previous head injury).

25. Intracerebral hemorrhage (ICH) is bleeding directly into the brain tissue, forming a gradually enlarging hematoma (pooling of blood). It generally occurs in small arteries or arterioles and is commonly due to hypertension, trauma, bleeding disorders, illicit drug use (e.g. amphetamines or cocaine), and vascular malformations. The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system, CSF or the pial surface. A third of intracerebral bleed is into the brain's ventricles. ICH has a mortality rate of 44 percent after 30 days, higher than ischemic stroke or even the very deadly subarachnoid hemorrhage.

26. Risk Factors

27. Diagnostics: Lumbar tap may be bloody, if hemorrhagic type CT scan shows edema, lesions, structural details with high accuracy MRI delineates size and location only Angiography shows arterial vessel shadow and can identify narrowing, blockage or rupture EEG can assess localized damage

28. Medical Mgt Administration of medications such as: Osmotic diuretics (Mannitol) Corticosteroids (Dexamethasone) Anticonvulsants (Tegretol, Dilantin) Muscle relaxants (Valium) Analgesics ( Morphine Sulfate) Anti-coagulants (Coumadin) Anti-hypertensive ( Nicardipine) Neuroprotective (Nootropil)

29. Surgical Mgt Craniectomy- surgical procedure wherein a portion of the cranium is removed to relieve pressure on the brain structures by providing space for expansion Craniotomy- surgical procedure wherein the cranial vault is opened to visualize and relieve pressure on the brain

30. Application of the Nursing Process Assessment

32. Signs and Symptoms of Stroke The symptoms of a stroke are related to the anatomical location of the damage; nature and severity of the symptoms can therefore vary widely. Ischemic strokes usually only affect regional areas of the brain perfused by the blocked artery. Hemorrhagic strokes can affect local areas, but often can also cause more global symptoms due to bleeding and increased intracranial pressure. On the basis of the history and neurological examination, as well as the presence of risk factors, a doctor can rapidly diagnose the anatomical nature of the stroke (i.e. which part of the brain is affected), even if the exact cause is not yet known.

33. If the area of the brain affected contains one of the three prominent Central Nervous System pathways—the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include: hemiplegia muscle weakness of the face numbness reduction in sensory or vibratory sensation

34. the brainstem consists of the 12 cranial nerves. A stroke affecting the brainstem therefore can produce symptoms relating to deficits in these cranial nerves: altered smell, taste, hearing, or vision (total or partial) drooping of eyelid (ptosis) and weakness of ocular muscles decreased reflexes: gag, swallow, pupil reactivity to light decreased sensation and muscle weakness of the face balance problems and nystagmus altered breathing and heart rate weakness in sternocleidomastoid muscle with inability to turn head to one side weakness in tongue (inability to protrude and/or move from side to side)

35. If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms: aphasia (inability to speak or understand language from involvement of Broca's or Wernicke's area) apraxia (altered voluntary movements) visual field defect memory deficits (involvement of temporal lobe) Hemineglect (involvement of parietal lobe) disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe) anosognosia (persistent denial of the existence of a, usually stroke-related deficit)

36. If the cerebellum is involved, the patient may have the following: trouble walking altered movement coordination vertigo and or disequilibrium

37. Loss of consciousness, headache , and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing on the brain.

38. Five major signs of stroke: Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. The loss of voluntary movement and/or sensation may be complete or partial. There may also be an associated tingling sensation in the affected area. Sudden confusion or trouble speaking or understanding. Sometimes weakness in the muscles of the face can cause drooling. Sudden trouble seeing in one or both eyes Sudden trouble walking , dizziness, loss of balance or coordination Sudden, severe headache with no known cause

39. Ineffective cerebral tissue perfusion Impaired physical mobility Impaired verbal (and/or written) communication Disturbed sensory perception Self-care deficit Ineffective coping Risk for impaired swallowing Risk for impaired skin integrity Knowledge deficit regarding condition, prognosis, treatment, self-care and discharge needs Nursing Diagnoses:

40. Nursing Priorities: Promote adequate cerebral perfusion and oxygenation Prevent/ minimize complications and permanent disabilities Assist patient to gain independence in ADLs Support coping process and integration of changes into self-concept Provide information about the disease process/ prognosis and treatment/ rehabilitation needs

41. Nursing interventions: Determine factors R/T individual situation Monitor/Document nuerological status frequently and compare with baseline Monitor V/S Evaluate pupils, noting size, shape, equality, light reactivity Document changes in vision Asses higher functions, including speech, if patient is alert Position with head slightly elevated and in neutral position Maintain bedrest; provide a quiet environment; restrict visitors/activities as indicated. Provide rest periods between care activities, limit duration of procedures. Prevent straining at stool, holding breath Asses for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity

42. Administer supplemental oxygen as indicated Administer medications as indicated Assess functional ability/ extent of impairment initially and on regular basis Change positions at least every 2 hours Prop extremities in functional position; use footboard during period of flaccid paralysis. Maintain neutral position in bed Observe affected side for color, edema, or other signs of compromised circulation Inspect skin regularly, particularly over body prominences. Begin active / passive ROM exercises to all extremities Provide egg crate mattress, water-bed or specialized beds as indicated Provide alternative methods of communication Talk directly to patient, speaking slowly and distinctly Speak in normal tones and avoid talking too fast Ensure safety at all times

43. Discharge goals: Cerebral function improved, neurological deficits resolving/ stabilized Complications prevented or minimized ADL needs met by self or with assistance of others Coping with situation in positive manner, planning for the future Disease process/ prognosis and therapeutic regimen understood Plan in place to meet needs after discharge

44. End of Discussion