Cerebrovascular Accident

CEREBRO VASCULAR DISORDER (CEREBRO VASCULAR ACCIDENT)

Dr. Jayesh Patidar www.drjayeshpatidar.blospot.com

INTRODUCTION

Cerebrovascular disorders is any functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. Stroke is the primary Cerebrovascular disorder in the United States and in the world. stroke is still the third leading cause of death.

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ANATOMY & PHYSIOLOGY OF NERVOUS SYSTEM

The nervous system is divided into two parts:

Central nervous system

Peripheral nervous system

ARTERIES: Two internal carotid arteries, Two vertebral arteries


DEFINITION

A stroke, or Cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die.


INCIDENCE

AGE : The percentage is higher for people age 65 and older. Of those who survive, 50% to 70% will be functioning independent and 15% to 30% will live with permanent disability.

SEX : Stroke is more common in men than in women.


RACE African american have a higher incidence of strokes than whites. This high incidence may be related to increase rate of hypertension,

diabetes mellitus and sickle cell anemia in african americans. African americans also have a higher incidence of smoking and

obesity than white, which are two other risk factors for stroke. African american are twice as likely to die from a strokes as white.

COUNTRY : An estimated 700,000 person in the united states and 50,000 in

canada suffer a stroke annually. Stroke is the third most commen cause of the death in the united

states and canada, behind cancer and heart disease. In canada about 16,000 die from stroke each year, while in united

states there are over 160,000 deaths from strokes.


ETIOLOGY

Nonmodifiable risk factors : Age : more than 65 yr Gender : More in men than women Race : African American Family history : Heredity Modifiable risk factors : Hypertension Heart disease Smoking


Excessive alcohol consumption

Obesity

Sleep apnea

Metabolic syndrome

Poor diet

Drug abuse

Oral contraceptive


Causes

Vessel wall embolus Carotid artery most often the source Related to thrombus formation distal to stenosis

Cardiac source Mitral valve stenosis Mitral valve prolapsed Calcified mitral annulus Ventricular aneurysm Atrial or ventricular clot Valvular vegetation Atrial septal defect


vascular sources

Intracranial artery thrombus (esp. African-Americans)

Aortic arch atherosclerotic Plaque

Transient hypotension with Carotid Stenosis


TYPES OF STROKE

Strokes are classified as ischemic or hemorrhagic

based on the underlying pathophysiologic

findings.


Ischemic stroke

An ischemic stroke result from inadequate blood flow to the brain from partial or complete occlusion of an artery. These account for approximately 80% of all strokes. Ischemic stroke are further divided into thrombotic and embolic.


Thrombotic stroke

A thrombotic stroke occurs from injury to a blood vessels wall and formation of a blood clot. The lumen of the blood vessel becomes narrowed and if it becomes occluded, infarction occur. Thrombosis develops readily where atherosclerotic plaques have already narrowed blood vessels. Thrombotic stroke, which is the result of thrombosis or narrowed blood vessel, is the most common cause of stroke. Two third of thrombotic strokes are associated with hypertension or diabetes mellitus


Embolic stroke

Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the bloodstream and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke.


CLINICAL MANIFESTATIONS

Visual Field Deficits : Homonymous hemianopsia (loss of half of the visual field) - Unaware of persons or objects on side of visual loss - Neglect of one side of the body - Difficulty judging distances Loss of peripheral vision -Difficulty seeing at night - Unaware of objects or the borders of objects Diplopia -Double vision


Motor Deficits

Hemiparesis Weakness of the face, arm, and leg non 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 Defective muscular co-ordination, unsteady gait Unable to keep

feet together; needs a broad base to stand Dysarthria Difficulty in forming words Dysphagia Difficulty in swallowing


Sensory Deficits

Paresthesia (occurs on the side opposite the lesion)

Numbness and tingling of Extremity


Verbal Deficits

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


Cognitive Deficits Short- and long-term memory loss Decreased attention span Impaired ability to concentrate Poor abstract reasoning Altered judgment Emotional Deficits Loss of self-control Emotional lability Decreased tolerance to stressful situations Depression Withdrawal Fear, hostility, and anger Feelings of isolation


ASSESSMENT AND DIAGNOSTIC FINDING HEALTH HISTORY : Past health history : Hypertension, previous stroke,

aneurysm, cardiac disease (including recent myocardial infraction), dysrhythmias, heart failure, valvular disease, infective endocarditis, hyperlipidemia, polycythemia, diabetes

Family history : Hypertension, diabetes, stroke, coronary artery disease.

Medications : Use of oral contraceptives, use of antihypertensive and anticoagulant therapy

Nutritional history : Anorexia, nausea, vomiting,dysphagia, altered sensation of taste and smell

Cognitive perceptual history : Numbness, tingling of one side of body, loss of memory, altered in speech, pain, headache, visual disturbance


PHYSICAL ASSESSMENT Glasgow coma scale

NIH stroke scale

COGNITIVE FUNCTION :-

Orientation :

Speech :-aphasia & other problems Fluent aphasia (motor/Borkas) inability to express

self

Non-fluent aphasia ( sensory / wernickes) inability to understand the spoken language.

Global aphasia inability to speak or understand spoken language.

Other aphasia syndromes amnesia, conduction.


Other alterations include : Confabulation fluent , nonsensical speech

Preservation continuation of thought process with inability to change rain of though without direction or repetition.

MOTOR FUNCTION :

-Voluntary movement -Reflexive movement : Biceps, Triceps, Patellar,

Achilles, Planter:


DIAGNOSTIC EVALUATION

Diagnosis of stroke, including extent of involvement

CT, CTA (computer tomographic angiography) MRI, MRA (magnetic resonance angiography) SPECT (single photon emission computed tomography) PET ( Positron emission tomography ) MRS (magnetic resonance spectroscopy) Xenon CT Electroencephalogram Cerebral angiography Cerebrospinal fluid analysis


CT SCAN


Cerebral blood flow measures

Cerebral angiography

Digital subtraction angiography

Doppler ultrasonography

Transcranial Doppler

Carotid duplex

Carotid angiography


Cardiac assessment

Electrocardiography

Chest x-ray

Cardiac enzymes

Holter monitor

Additional studies

Complete blood count

Prothrombin time, activated partial thromboplastin time

Electrolytes

Blood glucose level

Renal and hepatic studies

Lipid profile

Arterial blood gases analysis


MANAGEMENT :

MEDICAL MANAGEMENT :

Platelet-inhibiting medications : Aspirin, dipyridamole [Persantine], clopidogrel [Plavix], and ticlopidine [Ticlid]). Currently the most cost-effective antiplatelet regimen is aspirin 50 mg/d and dipyridamole 400 mg/d.

Thrombolytic therapy : Recombinant t-PA is a genetically engineered form of t PA, a thrombolytic substance made naturally by the body. The minimum dose is 0.9 mg/kg; the maximum dose is 90 mg.


Eligibility Criteria for t-PA Administration

Age 18 years or older Clinical diagnosis of stroke with NIH stroke scale score

under 22

Time of onset of stroke known and is 3 hours or less

BP systolic 185; diastolic 110

Not a minor stroke or rapidly resolving stroke

No seizure at onset of stroke

Not taking warfarin (Coumadin)

Prothrombin time 15 seconds or INR 1.7

Not receiving heparin during the past 48 hours with elevated partial thromboplastin time.


Platelet count 100,000

Blood glucose level between 50 and 400 mg/dL

No acute myocardial infarction

No prior intracranial hemorrhage, neoplasm, arteriovenous, malformation, or aneurysm

No major surgical procedures within 14 days

No stroke or serious head injury within 3 months

No gastrointestinal or urinary bleeding within last 21 days

Not lactating or postpartum within last 30 days


Surgical management

Carotid endarterectomy : Removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries. This surgery is indicated for patients with symptoms of TIA or mild stroke found to be due to severe (70% to 99%) carotid artery stenosis or moderate (50% to 69%) stenosis with other significant risk factors.


NURSING MANAGEMENT ASSESSMENT

Assess the level of consciousness or responsiveness as evidenced by movement, resistance to changes of position, and response to stimulation; orientation to time, place, and person

Presence or absence of voluntary or involuntary movements of the extremities; muscle tone; body posture; and position of the head

Stiffness or flaccidity of the neck

Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position


Color of the face and extremities; temperature and moisture of the skin

Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature,

and arterial pressure

Ability to speak

Volume of fluids ingested or administered; volume of urine excreted each 24 hours

Presence of bleeding

Maintenance of blood pressure within the desired parameters


NURSING DIAGNOSES Impaired physical mobility related to hemiparesis, loss

of balance and coordination, spasticity, and brain

injury

Acute pain related to hemiplegia and disuse of extrimity

Self-care deficits (hygiene, toileting, grooming, and feeding) related to stroke

Disturbed sensory perception related to altered sensory reception, transmission, and/or integration

Impaired swallowing

Incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating


Disturbed thought processes related to brain damage, confusion, or inability to follow

instructions

Impaired verbal communication related to brain damage

Risk for impaired skin integrity related to hemiparesis/ hemiplegia, or decreased

mobility

Interrupted family processes related to catastrophic illness and caregiving burdens

Sexual dysfunction related to neurologic deficits or fear of failure


Hemorrhagic strokes

Hemorrhagic strokes account for 15% of cerebrovascular disorders and are primarily caused by an intracranial or subarachnoid hemorrhage

Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% of hemorrhagic strokes and is primarily caused by uncontrolled hypertension


Pathophysiology

Etiological factors

presses on nearby cranial nerves or brain tissue

causing subarachnoid hemorrhage

increase in ICP resulting from the sudden entry of blood into the subarachnoid space,

injures brain tissue; or by secondary ischemia of the brain resulting from the reduced perfusion pressure


TYPE OF HEMORRHAGE

INTRACEREBRAL HEMORRHAGE

An intracerebral haemorrhage, or bleeding into the brain substance, is most common in patients with hypertension and cerebral atherosclerosis because degenerative changes from these diseases cause rupture of the vessel.


INTRACRANIAL (CEREBRAL) ANEURYSM

An intracranial (cerebral) aneurysm is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall.


SUBARACHNOID HEMORRHAGE :

A subarachnoid hemorrhage (hemorrhage into the subarachnoid space) may occur as a result trauma, or hypertension.


CLINICAL MANIFESTATIONS

Severe headache

Loss of consciousness

Rigidity of the back and neck (nuchal rigidity)

Pain in spine due to meningeal irritation

Visual disturbance (visual loss, diplopia, ptosis)

Dizziness

Hemiparesis


ASSESSMENT AND DIAGNOSTIC

FINDING : DIAGNOSTIC EVALUATION :

CT Scan : To determine the size and location of the hematoma as well as presence or absence of ventricular blood.

Cerebral angiography : To confirm the diagnosis of an aneurysm or AVM.

Lumber puncture PREVENTION: Control hypertension. Stop smoking. Stop to take alcohol. Avoid to take high cholesterol diet


SURGICAL MANAGEMENT

Craniotomy : Many patients with a primary intracerebral hemorrhage are not treated surgically. However, surgical evacuation is strongly recommended for the patient with a cerebellar hemorrhage if the diameter exceeds 3 cm. Surgical evacuation is most frequently accomplished via a craniotomy.


Extracranial-intracranial arterial bypass : An extracranial-intracranial arterial bypass may be performed to

establish collateral blood supply to allow surgery on the aneurysm. Alternatively, an extracranial method may be used, whereby the carotid artery is gradually occluded in the neck to reduce pressure within the blood vessel.


POST OPERATIVE COMPLICATIONS :

Intraoperative embolization

Postoperative internal artery occlusion

Fluid and electrolyte disturbances


NURSING DIAGNOSIS : Ineffective cerebral tissue perfusion related to

bleeding

Disturbed sensory perception related to medically imposed restrictions (aneurysm precautions)

Anxiety related to illness and/or medically imposed restrictions (aneurysm precaution)


HOME CARE Discuss measures to prevent subsequent strokes. Identify signs and symptoms of specific

complications.

Identify potential complications and discuss measures to prevent them (blood clots, aspiration, pneumonia, urinary tract infection, fecal impaction, skin breakdown, contracture).

Identify psychosocial consequences of stroke and appropriate interventions.

Identify safety measures to prevent falls. State names, doses, indications, and side effects of

medications.


Demonstrate adaptive techniques for accomplishing ADLs.

Demonstrate swallowing techniques (for patients with dysphagia).

Demonstrate care of enteric feeding tube, if applicable. Demonstrate home exercises, use of splints or

orthotics, proper positioning, and need for frequent repositioning.

Describe procedures for maintaining skin integrity. Demonstrate indwelling catheter care, if applicable.

Describe a bowel and bladder elimination program as appropriate.

Identify appropriate recreational or diversional activities, support groups, and community resources.


THANK YOU


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Cerebrovascular Accident