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Stroke
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- 3. INTRODUCTION The brain receivesabout 25% of the body's oxygen, but it cannot store it. Brain cells require a constant supply of oxygen to stay healthy and function properly. Therefore, blood needs to be supplied continuously to the brain through two main arterial systems: CAROTID ARTERY BASILAR ARTERY
- 4. CONT.. The carotid arteriescome up through either side of the front of the neck. The basilar artery forms at the base of the skull from the vertebral arteries, which run up along the spine, join, and come up through the rear of the neck.
- 5. Definition: Stroke occurs whenthere is ischemia (inadequate blood flow) to a part of the brain or hemorrhage into the brain that results in death of brain cells.
- 7. RISK FACTORS RISK FACTORSARE DIVIDED INTO : NON MODIFIABLE MODIFIABLE NONMODIFIABLE RISK FACTORS INCLUDE: AGE- Stroke increase with age GENDER- Equal in men and women RACE- HEREDITY- a family history of stroke
- 8. Modifiable Asymptomatic carotid stenosis D.M Heart diseases Atrialfibrillation Excessive Alcohol consumption Hypercoagulability Hyperlipidemia
- 9. Cont… HTN Obesity Oral contraceptive use Physicalinactivity Sickle cell disease(drepanocytosis) Smoking
- 10. TYPES OF STROKE Strokescan be divided into two major categories: ISCHEMIC(85%)- Stroke in which vascular occlusion and significant hypoperfusion occur. HEMORRHAGIC (15%)- in which there is extravasation of blood into the brain
- 12. Ischemic stroke Ischemic strokeresults from inadequate blood flow to the brain from partial or complete occlusion of an artery. It is further divided into: Thrombotic stroke. Embolic stroke.
- 13. THROMBOTIC Thrombotic strokes aredue to atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction. Thrombotic strokes have been preceded by TIA (transient ischemic attack ). TIA is a temporary loss of neurologic function caused by ischemia of one of the vascular territories of the brain due to micro emboli that temporarily block the blood flow.
- 15. EMBOLIC STROKE An embolusis a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood.
- 17. Hemorrhagic Stroke A burstof blood vessel may allow blood to seep into and damage the brain tissues until clotting shuts off the leak. It is further divided into two. Intra-cerebral hemorrhage(intra- parenchymal) Subarachnoid hemorrhage (intra- ventricular )
- 18. Intra-cerebral hemorrhage It isthe bleeding within the brain caused by a rupture of a vessel. Hypertension is the most important cause of intra- cerebral hemorrhage. There is most often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding. Symptoms include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness and hypertension.
- 19. Subarachnoid hemorrhage It occurswhen there is intracranial bleeding into cerebrospinal fluid filled space between the arachnoid and pia mater membranes on the surface of the brain. It commonly caused by rupture of a cerebral aneurysm. Common symptoms includes severe headache, sudden comatose, focal neurologic deficits, nausea, vomiting, seizures and stiff neck
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- 21. Obstruction of bloodvessel Disrupted cerebral blood flow Ischemia Neurons shift from aerobic respiration to anaerobic respiration Generates large amount of lactic acid (pH increases) Electrolyte balance fails Increases intracellular calcium and glutamate release Cell membranes and proteins brake down Cell injury and cell death
- 22. Ischemia Energy Failure Ion imbalance CellInjury & Death Cell membranes & proteins breakdown Formation of free Radicals Protein production decreased Pathophysiology Intracellular calcium increased Depolarization Increased Glutamate Hemorrhage Acidosis
- 23. CLINICAL MANIFESTATIONS • Astroke can cause a wide variety of neurologic deficits ,depending on the location of the lesion (which vessels are obstructed),the size of the area of inadequate perfusion, and the amount of secondary or accessory blood flow. Ischemia or haemorrhage to one side of the brain can often result in signs and symptoms on the opposite side of the body.
- 24. THE PATIENT MAYPRESENT WITH ANY OF THE FOLLOWING SIGNS OR SYMPTOMS: • 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 • Difficulty walking, dizziness, or loss of balance or coordination • Sudden severe headache
- 25. VISUAL FIELD DEFICITS •Hemianopsia -Loss of half of the visual field • Loss of peripheral vision - Difficulty seeing at night. Unaware of objects or the borders of objects • Diplopia - Double vision
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- 28. MOTOR DEFICITS • Hemiparesis–Weakness of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere) • Hemiplegia – Paralysis of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere). • Ataxia - Staggering, unsteady gait .Unable to keep feet together; needs a broad base to stand • Dysarthria - Difficulty in forming words • Dysphagia- Difficulty in swallowing.
- 29. SENSORY DEFICITS • Paresthesia- Numbness and tingling of extremity.
- 30. VERBAL DEFICITS (APHASIA) • Expressive aphasia - Unable to form words that are understandable; may be able to speak in single-word responses • Receptive aphasia -Unable to comprehend the spoken word; can speak but may not make sense • Global (mixed) aphasia -Combination of both receptive and expressive aphasia
- 31. COGNITIVE DEFICITS • Short-and long-term memory loss • Decreased attention span • Impaired ability to concentrate • Poor abstract reasoning • Altered judgment • Apraxia
- 32. EMOTIONAL DEFICITS • Lossof self-control • Emotional liability • Decreased tolerance to stressful situations • Depression • Withdrawal • Fear, hostility, and anger • Feelings of isolation
- 33. • Paralysis orweakness on left side of body • Left visual field deficit • Spatial-perceptual deficits • Increased distractibility • Impulsive behavior and poor judgment • Lack of awareness of deficits • Paralysis or weakness on right side of body • Right visual field deficit • Aphasia (expressive, receptive, or global) • Altered intellectual ability • Slow, cautious behavior COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES LEFT HEMISPHERIC STROKE RIGHT HEMISPHERIC STROKE
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- 36. DIAGNOSIS STUDIES Diagnostic studiesare done to: •Diagnosis of stroke ,including extent of involvement •To measure cerebral blood flow • To assess cardiac involvement
- 37. Diagnostic studies • Computedtomography angiography. • Magnetic resonance angiography • Single photon emission computed tomography (SPECT) • Positron emission tomography (PET) • Magnetic resonance spectroscopy (MRS) • Xenon CT • Electroencephalogram • Cerebral angiography • Cerebrospinal fluid analysis
- 38. •Digital subtraction angiography •Dopplerultrasonography •Trans-cranial Doppler •Carotid duplex •Carotid angiography
- 39. Cardiac assessment •Electrocardiogram •Chest x-ray •Cardiacenzymes • Echocardiaography •Holter monitoring
- 40. Additional studies •Cbc/ FBC •Platelets,PT, Activated partial thromboplastin time. •Electrolytes, Blood glucose •Renal and hepatic studies •Lipid profile •ABG
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- 42. PHARMACOLOGICAL MANAGEMENT • ANTIPLATELET DRUG e.g.: ASPIRIN,CLOPIDOGREL (dose:81-325 mg/day). • ANTICOAGULANT E.g.: warfarin • THROMBOLYTIC THERAPY Recombinant t-PA thrombolytic substance made naturally by the body works by binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the atherosclerotic lesion.
- 43. Cont.. • CALCIUM CHANNELBLOCKER Nimodipine is given to patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize cerebral damage. • ANTISEIZURE DRUGS Phenytoin is given if seizure occurs. • ANALGESICS • codeine, acetaminophen may be prescribed for head and neck pain.
- 44. Cont… • DIURETIC DRUGS itis used to reduce cerebral edema and it also helps in lowering ICP E.g.: MANNITOL , FUROSEMIDE.
- 45. NON-PHARMACOLOGICAL MANAGEMENT •Maintain ABC. •Reducesalt and sodium intake •Maintain a normal body weight •Maintain a normal blood pressure •Increase level of physical exercise •Avoid cigarette smoking or tobacco products
- 46. Cont… •Limit consumption ofalcohol to moderate levels •Use a diet that is low in saturated fat and dietary cholesterol and high in fruits and vegetables. •The patient is fitted with elastic compression stockings to prevent deep vein thrombosis, a threat to any patient on bed rest.
- 47. SURGICAL MANAGEMENT • Carotidendarterectomy The artheromatous lesion is removed from the carotid artery and to improve blood flow. • Transluminal angioplasty - It is the insertion of a balloon to open a stenosed artery and improve blood flow. • EC-IC bypass It involves anastomosing a branch of an extracranial artery to an intracranial artery beyond the area of obstruction with the goal of increasing cerebral perfusion. Merci retriever-it removes the blood clots by going into the artery that is blocked and pulls the clot out.
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- 50. For aneurysm andhemorrhage • CLIPPING AND WRAPPING. It’s a traditional method to prevent rebleeding. • COILING It’s a endovascular procedure done by inserting a metal coil (GDC’S) into the lumen and thus provides immediate protection against bleeding and reduce the pulsation within the aneurysm.
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- 54. a. Nursing Responsibilities Therole of a nurse in taking care of a patient with CVA are: 1. Improve physical mobility and prevent joint deformities by providing correct positioning and assist the patient in maintain good body alignment. 2. The arm of the patient is slightly flexed with a pillow under the arm where elbow is positioned higher than shoulder and the wrist higher than elbow to prevent edema.
- 55. Cont… 3.Change the positionof the patient every 2 hours to prevent pressure sores. 4.Provide passive exercises to affected extremities four or five times a day to maintain mobility, motor control which helps in preventing venous stasis.
- 56. CVA positioning inbed..
- 57. Cont.. 5. Ambulate thepatient as soon as possible when the patient can be assisted out of bed. 6. The nurse should never lift or pull the patient by the affected shoulder . The proper positioning and range of exercise reduce shoulder pain.
- 58. Cont.. 7.The nurse shouldencourage the patient to do self care activities. 8.The role of a nurse is to support the client in improving thought process in collaboration with primary care physician neuropsychologist and other professionals.
- 59. Cont.. 9. The patientskin must be kept clean and dry .Maintain normal skin and tissue integrity by providing adequate nutrition. 10.Educate and counsel the family members who play an important role in the patients recovery.
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- 61. CVA diagnosis are: 1.Ineffective cerebral tissue perfusion related to decreased cerebral blood flow as evidenced by decreased GCS. 2. Impaired physical mobility related to hemiparesis, loss of balance and co-ordination and brain injury as evidenced by limited ability to perform activities.
- 62. Cont.. 3. Impaired verbal communicationrelated to brain damage as evidenced by inability to speak or find words. 4. Self care deficit related to stroke squeals as evidenced by inability in performing daily course.
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