Stroke Charlene Morris, RN, MSN With grateful acknowledgment to Marnie Quick, RN, MSN, CNRN

StrokeStrokeCharlene Morris, RN, MSNCharlene Morris, RN, MSN

With grateful acknowledgment to With grateful acknowledgment to Marnie Quick, RN, MSN, CNRN Marnie Quick, RN, MSN, CNRN

The BrainThe BrainLewis – Chapter 56 for A & P review, neuro Lewis – Chapter 56 for A & P review, neuro assessment, p. 1460 for neuro abnormalities assessment, p. 1460 for neuro abnormalities vocabulary, and p. 1462 for diagnostic tests.vocabulary, and p. 1462 for diagnostic tests.

http://www.strokecenter.org/prof/http://www.strokecenter.org/prof/– Provides a review of pathophysiology of the brain Provides a review of pathophysiology of the brain

and surrounding tissues, diagnostic tests, vocabulary, and surrounding tissues, diagnostic tests, vocabulary, etc. etc.

These will help you to understand deficits These will help you to understand deficits experienced by patients having various types of experienced by patients having various types of strokes or injuries. strokes or injuries.

Hearing/association & Smell & taste Short term Memory

Voluntary Motor

Sensations Pain & Touch Taste

Balance, Coordination of each muscle group

Arms

Head

LegsMom: Bowel/bladder Reasoning/judgment Long term memory

Vision & visual memory

CN 5,6,7,8 P,R, B/P CN 9,10,11,12

Tracks cross over Coordinate movement, HR,B/P

Cerebral cortex functionsCerebral cortex functions

Vessels of the BrainVessels of the Brain

Vessels of the BrainVessels of the Brain

Right Side

Circle of WillisCircle of Willis

Blood distribution to areas Blood distribution to areas

of the brainof the brain

Right side

LeMone page 1309

PhysiologyPhysiologyNormal Cerebral Blood FlowNormal Cerebral Blood Flow

Venous plexuses – Venous plexuses – Internal jugular veinsInternal jugular veinsVertebral veinsVertebral veinsNo valves, depend on gravity and venous pressure gradient for No valves, depend on gravity and venous pressure gradient for flowflow

Cerebral cortex functionsCerebral cortex functions

Swallowing

Careful, slow, & anxious

Deny deficits & impulsive, short attention span

Incidence & Prevalence – 2007-08Incidence & Prevalence – 2007-08

Third leading cause of death in the USAThird leading cause of death in the USA– 750,000+ people/year have a stroke750,000+ people/year have a stroke– Of those 175,000 die within one year (25%)Of those 175,000 die within one year (25%)

Leading cause of long-term disabilities Leading cause of long-term disabilities – Estimated 5.5 million survivors of stroke in the Estimated 5.5 million survivors of stroke in the

USAUSA– 15 to 30 % live with permanent disability15 to 30 % live with permanent disability

Heart Disease and Stroke Heart Disease and Stroke Statistics Statistics —— 2009 Update 2009 Update

Estimated direct and indirect costs (in billions of dollars) of Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke major cardiovascular diseases and stroke (United States: 2009). (United States: 2009). Source: NHLBI.Source: NHLBI.

165.4

68.9 73.4

37.2

0

40

80

120

160

200

Coronary HeartDisease

Stroke HypertensiveDisease

Heart Failure

Bil

lio

ns

of

Do

llar

s

Direct Costs of the 10 Leading Diagnostic Groups Direct Costs of the 10 Leading Diagnostic Groups

(United States: 2009)(United States: 2009). . Source: NHLBI. Source: NHLBI.

85

99

122.3

155.3

166.8

172

172.5

218.4

91.1

313.8

0 50 100 150 200 250 300 350

Endocrine System 240-279

Genitourinary System 580-629

Neoplasms 140-239

Musculoskeletal system 710-739

Respiratory System 460-519

Injury and Poisoning 800-999

Nervous System 320-389

Mental 290-319

Digestive System 520-579

Cardiovascular 340-459

Risk FactorsRisk FactorsNon-modifiableNon-modifiable

AgeAge2/3 over 65, any age possible2/3 over 65, any age possible

GenderGenderEqual for men and women - women dying more Equal for men and women - women dying more often often

RaceRaceAfrican-Americans are more at risk for African-Americans are more at risk for ischemicischemic strokes then Hispanics, Native Americansstrokes then Hispanics, Native AmericansAsians more at risk for Asians more at risk for hemorrhagic strokeshemorrhagic strokes

Heredity:Heredity: Family history or previous TIA/CVA Family history or previous TIA/CVA

Risk FactorsRisk FactorsModifiable Modifiable

HypertensionHypertension

Diabetes mellitusDiabetes mellitus

Heart diseaseHeart disease

A-fibA-fib

Asymptomatic carotid Asymptomatic carotid stenosisstenosis

HyperlipidemiaHyperlipidemia

ObesityObesity

Oral contraceptive useOral contraceptive use

Heavy alcohol useHeavy alcohol use

Physical inactivityPhysical inactivity

Sickle cell diseaseSickle cell disease

SmokingSmoking

Procedure precautionsProcedure precautions

In a recent study of 15,693 people age 60 years old or above and with systolic blood pressures of 160 or more and diastolic pressures of 95 or more, without treatment each 10 mmHg rise in systolic blood pressure increased the risk of stroke by 26%


Requires oxygen and glucose to functionRequires oxygen and glucose to function20% of Cardiac Output / oxygen 20% of Cardiac Output / oxygen Arterial supply to the brain:Arterial supply to the brain:– Internal carotid (anteriorly)Internal carotid (anteriorly)– Vertebral arteries (posteriorly)Vertebral arteries (posteriorly)

Venous drainageVenous drainage– 2 sets of veins - venous plexuses 2 sets of veins - venous plexuses

– Dural sinuses to internal jugular veinsDural sinuses to internal jugular veins– Sagittal sinus to vertebral veinsSagittal sinus to vertebral veins

– No valves, depend on gravity and venous No valves, depend on gravity and venous pressure gradient for flowpressure gradient for flow


Cerebral Autoregulation of blood flowCerebral Autoregulation of blood flow– Autoregulation allows brain to keep constant Autoregulation allows brain to keep constant

blood flow regardless of systemic pressuresblood flow regardless of systemic pressuresMAP must be between 50 -150 mmHgMAP must be between 50 -150 mmHg

– MAP =MAP = (2 X diastolic B/P) + systolic B/P (2 X diastolic B/P) + systolic B/P Normal is 70 to 110 mm hg Normal is 70 to 110 mm hg

33

– Flow of venous blood is dependent on gravity Flow of venous blood is dependent on gravity and pressure differences between venous and pressure differences between venous sinuses and extracranial veinssinuses and extracranial veins

– Will autoregulation be altered by:Will autoregulation be altered by: ICP?ICP?Valsalva’s maneuver?Valsalva’s maneuver?Flexion of the neck?Flexion of the neck?

PhysiologyPhysiologyAltered Cerebral Blood FlowAltered Cerebral Blood Flow

What happens with HTN?What happens with HTN? flow, distention of vesselsflow, distention of vessels

What else can affect blood flow?What else can affect blood flow?– CO2CO2

CO2 causes CO2 causes blood flow blood flow

– O2 O2 O2 causes O2 causes blood flow blood flow

– H+ ionsH+ ions H+ causes H+ causes blood flow blood flow

PathophysiologyPathophysiologyAltered Cerebral Blood FlowAltered Cerebral Blood Flow

When cerebral blood flow is interrupted:When cerebral blood flow is interrupted:– 30 sec.: Neurological metabolism altered30 sec.: Neurological metabolism altered– 2 min: Neurological metabolism stops2 min: Neurological metabolism stops– 5 min: Cellular death occurs5 min: Cellular death occurs

PathophysiologyPathophysiologyAltered Cerebral Blood FlowAltered Cerebral Blood Flow

A band of minimally perfused cells A band of minimally perfused cells

that surround a core of dead or that surround a core of dead or

Dying cellsDying cells– These cells can survive if:These cells can survive if:

Return of adequate circulationReturn of adequate circulation

Minimal toxic products from Minimal toxic products from

adjacent dying cellsadjacent dying cells

– Low degree of edemaLow degree of edema

PenumbraPenumbra

Types of StrokeTypes of Stroke

Ischemic Stroke (85%)Ischemic Stroke (85%)– TIATIA

– Thrombotic StrokeThrombotic StrokeLacunar StrokeLacunar Stroke

– Embolic StrokeEmbolic Stroke

Transient Ischemic AttackTransient Ischemic Attack

Warning sign for strokeWarning sign for stroke

Brief localized ischemiaBrief localized ischemia

Common Common manifestations:manifestations:– Contralateral numbness/Contralateral numbness/

weakness of hand, weakness of hand, forearm, corner of mouthforearm, corner of mouth

– AphasiaAphasia– Visual disturbances- Visual disturbances-

blurringblurring

Deficits last less than Deficits last less than 24 hours (usually less 24 hours (usually less than 1 or 2 hrs)than 1 or 2 hrs)Can occur due to:Can occur due to:– Inflammatory artery Inflammatory artery

disordersdisorders– Sickle cell anemiaSickle cell anemia– Atherosclerotic Atherosclerotic

changeschanges

Act F.A.S.TAct F.A.S.T. .

FFACE Ask the person to smile.ACE Ask the person to smile.

Does one side of the face droop? Does one side of the face droop? AARMS Ask the RMS Ask the person to raise both arms.person to raise both arms.

Does one arm drift downward? Does one arm drift downward? SSPEECH Ask the PEECH Ask the person to repeat a simple sentence.person to repeat a simple sentence.

Are the words slurred? Can he/she repeat the Are the words slurred? Can he/she repeat the sentence correctly? sentence correctly? TTIME If the person shows any of these symptoms, IME If the person shows any of these symptoms, time is important. time is important.

Call 911 or get to the hospital fast. Brain cells are Call 911 or get to the hospital fast. Brain cells are dying. dying.

Stroke Symptoms include:Stroke Symptoms include:

SUDDEN numbness or weakness of face, arm or leg - especially on one side of the SUDDEN numbness or weakness of face, arm or leg - especially on one side of the body. body.

SUDDEN confusion, trouble speaking or understanding. SUDDEN confusion, trouble speaking or understanding.

SUDDEN trouble seeing in one or both eyes. SUDDEN trouble seeing in one or both eyes.

SUDDEN trouble walking, dizziness, loss of balance or coordination. SUDDEN trouble walking, dizziness, loss of balance or coordination.

SUDDEN severe headache with no known cause.SUDDEN severe headache with no known cause.

Call 9-1-1 immediately if you have any of these symptomsCall 9-1-1 immediately if you have any of these symptoms

Note the time you experienced your first symptom. This information is Note the time you experienced your first symptom. This information is important to your healthcare provider and can affect treatment decisions. important to your healthcare provider and can affect treatment decisions.

If you have experienced any of these symptoms, you may have had a If you have experienced any of these symptoms, you may have had a TIA or mini-strokeTIA or mini-stroke. .

Thrombotic StrokeThrombotic Stroke

Occlusion of large Occlusion of large cerebral vesselcerebral vessel– Lacunar strokes affect Lacunar strokes affect

smaller cerebral vesselssmaller cerebral vessels

Occur in Occur in older populationolder population, , while while sleeping/restingsleeping/resting

Rapid event, but Rapid event, but slow slow progression (usually reach progression (usually reach max deficit in 3 days)max deficit in 3 days)

Lacunar Strokes - 20% of all stokes Lacunar Strokes - 20% of all stokes The The small areas of cells distal to the occlusion die usually causing small areas of cells distal to the occlusion die usually causing only minor deficits only minor deficits – If the infarction is critically located, paralysis and sensory loss may If the infarction is critically located, paralysis and sensory loss may

result.result.Within a few months of the infarction, the necrotic brains cells are Within a few months of the infarction, the necrotic brains cells are reabsorbed by macrophage activity, leaving a very small cavity a reabsorbed by macrophage activity, leaving a very small cavity a lake or lacune in Frenchlake or lacune in FrenchCommon sites are occlusions of small, deep penetrating arteries Common sites are occlusions of small, deep penetrating arteries from: from: – middle cerebral artery middle cerebral artery – penetrating branches of the circle of Willis penetrating branches of the circle of Willis – vertebral or basilar arteries vertebral or basilar arteries

High incidence: High incidence: – Chronic hypertension Chronic hypertension – ElderlyElderly– DICDIC

Diagnosis Diagnosis – CT and MRI (more accurate)CT and MRI (more accurate)– Accuracy of diagnosis is a function of the severity of the deficit.Accuracy of diagnosis is a function of the severity of the deficit.

Embolic StrokeEmbolic Stroke

Embolus becomes lodged in Embolus becomes lodged in vessel and causes occlusionvessel and causes occlusionBifurcations are most common Bifurcations are most common sitesiteSudden onset with immediate Sudden onset with immediate deficitsdeficits– If clot is “busted” and body If clot is “busted” and body

reabsorbs, symptoms can reabsorbs, symptoms can disappeardisappear

– Vessel wall is weakened where Vessel wall is weakened where clot lodges which increases risk for clot lodges which increases risk for hemorrhage hemorrhage

Hemorrhagic Hemorrhagic TransformationTransformation

Types of StrokeTypes of Stroke

Hemorrhagic Stroke (15%)Hemorrhagic Stroke (15%)– Intracerebral HemorrhageIntracerebral Hemorrhage– Subarachnoid HemorrhageSubarachnoid Hemorrhage

Hemorrhagic StrokeHemorrhagic Stroke

Rupture of vesselRupture of vessel

Occurs suddenly, Occurs suddenly, usually when active, usually when active, most often fatalmost often fatal

Occurs most often in Occurs most often in clients with sustained clients with sustained HTN, or traumaHTN, or trauma

Rapid onset, varied Rapid onset, varied manifestationsmanifestations

From: Lewis, Heitkemper, and DirksenFrom: Lewis, Heitkemper, and DirksenMedical-Surgical Nursing 6Medical-Surgical Nursing 6thth Ed. p. 1528 Ed. p. 1528

TypeType Gender/AgeGender/Age WarningWarning Time of OnsetTime of Onset Course/PrognosisCourse/Prognosis

Ischemic:Ischemic:

ThromboticThrombotic

Men more than Men more than women; oldest women; oldest median agemedian age

TIA in 30-TIA in 30-50% of cases50% of cases

During or after sleepDuring or after sleep Stepwise progression, signs Stepwise progression, signs and symptoms develop and symptoms develop slowly, usually some slowly, usually some improvement, recurrence in improvement, recurrence in 20-25% of survivors20-25% of survivors

Ischemic: Ischemic: EmbolicEmbolic

Men more than Men more than womenwomen

TIA TIA (uncommon)(uncommon)

May or may not be May or may not be related to activity related to activity depending on source depending on source of embolus, of embolus,

sudden onsetsudden onset

Single event, signs and Single event, signs and symptoms develop quickly, symptoms develop quickly, usually some improvement, usually some improvement, recurrence common without recurrence common without aggressive treatment of aggressive treatment of underlying diseaseunderlying disease

Hemorrhagic: Hemorrhagic: IntracerebralIntracerebral

Slightly higher in Slightly higher in womenwomen

Headache Headache (25% of (25% of cases)cases)

Activity (often)Activity (often) Progression over 24 hr; poor Progression over 24 hr; poor prognosis, fatality more likely prognosis, fatality more likely with presence of comawith presence of coma

Hemorrhagic:Hemorrhagic:

SubarachnoidSubarachnoid

Slightly higher in Slightly higher in women, youngest women, youngest median agemedian age

Headache Headache (common)(common)

Activity (often), Activity (often), sudden onset; Most sudden onset; Most commonly related to commonly related to head traumahead trauma

Single sudden event usually, Single sudden event usually, fatality more likely with fatality more likely with presence of comapresence of coma

ManifestationsManifestationsby Vesselby Vessel

Internal carotid arteryInternal carotid artery– Contralateral paralysis (arm, leg, face)Contralateral paralysis (arm, leg, face)– Contralateral sensory deficitsContralateral sensory deficits– Aphasia (dominant hemisphere involvement)Aphasia (dominant hemisphere involvement)– Apraxia (motor task), Apraxia (motor task), – Agnosia (obj. recognition), Agnosia (obj. recognition), – Unilateral neglect (non-dominant hemisphere Unilateral neglect (non-dominant hemisphere

involvement)involvement)– Homonymous hemianopiaHomonymous hemianopia


Middle Cerebral Artery InvolvementMiddle Cerebral Artery Involvement– Contralateral weakness or paralysisContralateral weakness or paralysis– Contralateral hemianesthesiaContralateral hemianesthesia– Loss of proprioception, fine touch, localizationLoss of proprioception, fine touch, localization– Aphasia (dominant hemisphere involvement)Aphasia (dominant hemisphere involvement)– Anosognosia - neglect of paralyzed side Anosognosia - neglect of paralyzed side (non-dominant hemisphere involvement)(non-dominant hemisphere involvement)– Homonymous hemianopiaHomonymous hemianopia– primary motor and sensory areas of the face, throat, primary motor and sensory areas of the face, throat,

hand and arm and in the dominant hemisphere, the hand and arm and in the dominant hemisphere, the areas for speech. areas for speech. The middle cerebral artery is the The middle cerebral artery is the artery most often occluded in stroke. artery most often occluded in stroke.


Anterior Cerebral ArteryAnterior Cerebral Artery (if occlusion is distal to (if occlusion is distal to anterior communicating artery)anterior communicating artery)– Contralateral sensory/motor deficits of foot and legContralateral sensory/motor deficits of foot and leg– Contralateral weakness of proximal upper extremityContralateral weakness of proximal upper extremity– Urinary incontinenceUrinary incontinence– Sensory lossSensory loss– Apraxia (purposeful motor tasks)Apraxia (purposeful motor tasks)– Personality change Personality change

Flat affect, loss of spontaneity, loss of interest in surroundings, Flat affect, loss of spontaneity, loss of interest in surroundings, distractibility, slow responsesdistractibility, slow responses

– Possible cognitive impairment sPossible cognitive impairment supplies the frontal lobes, upplies the frontal lobes, the parts of the brain that control logical thought, the parts of the brain that control logical thought, personality, and voluntary movement, especially the personality, and voluntary movement, especially the legs. Stroke in the anterior cerebral artery results in legs. Stroke in the anterior cerebral artery results in opposite leg weakness. If both anterior cerebral opposite leg weakness. If both anterior cerebral territories are affected, profound mental symptoms territories are affected, profound mental symptoms may result (akinetic mutism). may result (akinetic mutism).


Vertebral ArteryVertebral Artery– Pain in face, nose, or eyePain in face, nose, or eye– Numbness and weakness of face (involved Numbness and weakness of face (involved

side)side)– Gait disturbancesGait disturbances– DysphagiaDysphagia– Dysarthria (motor speech) Dysarthria (motor speech)

Additional Site Related Deficits Additional Site Related Deficits

Brain Stem / Cerebellum / Posterior Hemisphere Stroke:Brain Stem / Cerebellum / Posterior Hemisphere Stroke:Common PatternsCommon PatternsMotor or sensory loss in all four limbs Motor or sensory loss in all four limbs Crossed signs Crossed signs Limb or gait ataxia Limb or gait ataxia Dysarthria Dysarthria Dysconjugate gaze Dysconjugate gaze Nystagmus Nystagmus Amnesia Amnesia Bilateral visual field defects Bilateral visual field defects Small Subcortical Hemisphere or Brain Stem (Pure Motor) Small Subcortical Hemisphere or Brain Stem (Pure Motor) Stroke: Common PatternStroke: Common PatternWeakness of face and limbs on one side of the body without abnormalities Weakness of face and limbs on one side of the body without abnormalities of higher brain function, sensation, or vision of higher brain function, sensation, or vision Small Subcortical Hemisphere or Brain Stem (Pure Sensory) Stroke: Small Subcortical Hemisphere or Brain Stem (Pure Sensory) Stroke: Common PatternCommon Pattern Decreased sensation of face and limbs on one side of the body without Decreased sensation of face and limbs on one side of the body without abnormalities of higher brain function, motor function, or vision abnormalities of higher brain function, motor function, or vision

Initial Stroke Assessment/InterventionsInitial Stroke Assessment/Interventions

Neurological assessment & NIH assessmentNeurological assessment & NIH assessmentCall “Stroke Alert” Code Call “Stroke Alert” Code Ensure patient airway Ensure patient airway – Remove dental devicesRemove dental devices

Get VS, including pulse ox & Oxygen if neededGet VS, including pulse ox & Oxygen if neededIV access, maintain BP within parametersIV access, maintain BP within parametersPosition head midlinePosition head midlineHOB 30 (if no shock/injury)HOB 30 (if no shock/injury)CT, blood work, data collection/NIH Stroke ScaleCT, blood work, data collection/NIH Stroke ScaleAnticipate thrombolytic therapy for ischemic Anticipate thrombolytic therapy for ischemic strokestroke

Initial Stroke Initial Stroke Assessment/InterventionsAssessment/Interventions

Tests for the Emergent Evaluation of the Patient with Acute Tests for the Emergent Evaluation of the Patient with Acute Ischemic StrokeIschemic StrokeCT of the brain without contrast CT of the brain without contrast Electrocardiogram Electrocardiogram Chest x-ray Chest x-ray Hematologic studies (complete blood count, platelet Hematologic studies (complete blood count, platelet count, prothrombin time, partial thromboplastin time) count, prothrombin time, partial thromboplastin time) Serum electrolytes Serum electrolytes Blood glucose Blood glucose Renal and hepatic chemical analyses Renal and hepatic chemical analyses National Institutes of Health Scale (NIHSS) score National Institutes of Health Scale (NIHSS) score

http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

Be sure to review administration of this scale.

Interval: [ ] Baseline

[ ] 2 hours post treatment

[ ] 24 hours post onset of symptoms ±20 minutes

[ ] 7-10 days

[ ] 3 months

[ ] Other _______

NIH Stroke Scale ScoreNIH Stroke Scale Score

Standardized method to measure degree of stroke related impairment and Standardized method to measure degree of stroke related impairment and change in a patient over time.change in a patient over time.

Helps determine if degree of disability merits treatment with Helps determine if degree of disability merits treatment with tPAtPA. . – As of 2008 stroke patients scoring greater than 4 points can be treated with tPA.As of 2008 stroke patients scoring greater than 4 points can be treated with tPA.

Standardized research tool to compare efficacy stroke treatments and Standardized research tool to compare efficacy stroke treatments and rehabilitation interventions.rehabilitation interventions.

Measures several aspects of brain function, including consciousness, vision, Measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language not measured by Glasgow coma sensation, movement, speech, and language not measured by Glasgow coma scale.scale.

Current NIH Stroke Score guidelines for measuring stroke severity:Current NIH Stroke Score guidelines for measuring stroke severity: Points are given for each impairment.Points are given for each impairment.

– 0= no stroke 0= no stroke – 1-4= minor stroke 1-4= minor stroke – 5-15= moderate stroke 5-15= moderate stroke – 15-20= moderate/severe stroke 15-20= moderate/severe stroke – 21-42= severe stroke21-42= severe stroke– A maximal score of 42 represents the most severe and devastating stroke. A maximal score of 42 represents the most severe and devastating stroke.

Diagnostic TestsDiagnostic Tests

CT = computed tomography - bleed, defects, CT = computed tomography - bleed, defects, ischemia, tumors, edemaischemia, tumors, edema

CTA = computed tomography angiography – CTA = computed tomography angiography – spasms, stenosis, vessel structure damage spasms, stenosis, vessel structure damage

MRI = magnetic resonance imaging – bleed or MRI = magnetic resonance imaging – bleed or edemaedema

MRA = magnetic resonance angiography - clotMRA = magnetic resonance angiography - clot

http://http://www.strokecenter.org/profwww.strokecenter.org/prof


MRS = magnetic resonance spectroscopy – MRS = magnetic resonance spectroscopy – determines ATP, lactate levels and pH to locate determines ATP, lactate levels and pH to locate penumbrapenumbra

PET = positron emission tomography – blood PET = positron emission tomography – blood flow & metabolismflow & metabolism

SPECT = single photon emission computed SPECT = single photon emission computed tomography –dye/planes cause of CVA, assess tomography –dye/planes cause of CVA, assess TIA not seen with CT, blood flowTIA not seen with CT, blood flow

EEG = electroencephalogram – seizures, injuryEEG = electroencephalogram – seizures, injury

CSF fluid analysis CSF fluid analysis (avoid if (avoid if ICP suspected – ICP suspected – with thrombic CVA)with thrombic CVA)


Blood Flow MeasurementsBlood Flow Measurements– rSO2 Cerebral Oximetry (Pulse Ox of brain)rSO2 Cerebral Oximetry (Pulse Ox of brain)– Cerebral angiographyCerebral angiography– Doppler ultrasonographyDoppler ultrasonography– Transcranial dopplerTranscranial doppler– Carotid duplexCarotid duplex– Carotid angiographyCarotid angiography


Cardiac AssessmentCardiac Assessment– ElectrocardiogramElectrocardiogram– Chest X-rayChest X-ray– Cardiac enzymesCardiac enzymes– Echocardiography Echocardiography

Transthoracic (TTE), Transesophageal (TEE)Transthoracic (TTE), Transesophageal (TEE)

– Holter monitor (arrhythmia evaluation)Holter monitor (arrhythmia evaluation)

Why is a cardiac assessment important?Why is a cardiac assessment important?

Additional StudiesAdditional Studies

CBCCBC

PT, INR, aPTTPT, INR, aPTT

Electrolytes, blood glucoseElectrolytes, blood glucose

Renal studiesRenal studies

Hepatic studiesHepatic studies

Lipid profileLipid profile

ABG (possible hypoxia)ABG (possible hypoxia)

MedicationsMedicationsPreventionPrevention- anti-platelet for TIA due to atherosclerosis - anti-platelet for TIA due to atherosclerosis – ASA (ASA (acetylsalicylic acid) acetylsalicylic acid) – Ticlid (Ticlopidine Hcl) Ticlid (Ticlopidine Hcl) – Plavix (Plavix (ClopidogrelClopidogrel))– Persantine (Dipyridamole) or Aggrenox (Persantine & Aspirin)Persantine (Dipyridamole) or Aggrenox (Persantine & Aspirin)Acute treatment Acute treatment – Anti-coagulants – A fib & TIAAnti-coagulants – A fib & TIA– Antithrombotics Antithrombotics – Calcium channel blockers – Nimotop (nimodipine) Calcium channel blockers – Nimotop (nimodipine) – Corticosteroids ???Corticosteroids ???– Thrombolytics - tPA (recombinant tissue plasminogen activator)Thrombolytics - tPA (recombinant tissue plasminogen activator)– Diuretics – Mannitol, Lasix (Furosemide)Diuretics – Mannitol, Lasix (Furosemide) – Anticonvulsants – Dilantin (phenytoin)Anticonvulsants – Dilantin (phenytoin) or or CerebyxCerebyx

(Fosphenytoin Sodium Injection) (Fosphenytoin Sodium Injection)

MedicationsMedications

Thrombolytics Recombinant Alteplase (rtPA) Thrombolytics Recombinant Alteplase (rtPA) Activase, Tissue plasminogen activatorActivase, Tissue plasminogen activator– Treatment must be initiated promptly after CT to R/O Treatment must be initiated promptly after CT to R/O

bleedbleedSystemic within 3 hours of onset of symptomsSystemic within 3 hours of onset of symptomsIntra-arterial within 6 hours of symptomsIntra-arterial within 6 hours of symptoms

– Some exclusions:Some exclusions:Seizure at onsetSeizure at onsetSubarachnoid hemorrhage Subarachnoid hemorrhage Trauma within 3 monthsTrauma within 3 monthsHistory of prior intracranial hemorrhageHistory of prior intracranial hemorrhageAV malformation or aneurysmAV malformation or aneurysmSurgery 14 days, pregnancy,Surgery 14 days, pregnancy,Cardiac cath. 7 daysCardiac cath. 7 days

TreatmentTreatmentSurgicalSurgical– Carotid endarterectomyCarotid endarterectomy– Merci clot removalMerci clot removal– Extracranial-intracranial bypassExtracranial-intracranial bypass– Decompression Decompression

Physical therapyPhysical therapyOccupational therapyOccupational therapySpeech therapySpeech therapy

Note: Note: No Rehab until stroke is “completed” (can take 3-10 days)No Rehab until stroke is “completed” (can take 3-10 days)

Until that time, no increased activity, and position per MD orderUntil that time, no increased activity, and position per MD orderBasic care, possible ROM, positioning, oral care, etc.Basic care, possible ROM, positioning, oral care, etc.

Stroke AssessmentStroke AssessmentNeurological assessment & NIH assessmentNeurological assessment & NIH assessment

Left (Dominant) Hemisphere Stroke: Common PatternLeft (Dominant) Hemisphere Stroke: Common Pattern Aphasia and/or Dysarthria Aphasia and/or Dysarthria Difficulty reading, writing, or calculating Difficulty reading, writing, or calculating Right hemiparesis and/or Right-sided sensory loss Right hemiparesis and/or Right-sided sensory loss Right visual field defect Right visual field defect Poor right conjugate gaze Poor right conjugate gaze Aware of deficits, cautious, slow, anxiousAware of deficits, cautious, slow, anxious

Right (Non-dominant) Hemisphere Stroke: Common PatternRight (Non-dominant) Hemisphere Stroke: Common Pattern Neglect of left visual field and/or Left visual field defect Neglect of left visual field and/or Left visual field defect Extinction of left-sided stimuli and/or Left-sided sensory loss -Extinction of left-sided stimuli and/or Left-sided sensory loss -neglectneglectLeft hemiparesisLeft hemiparesisPoor left conjugate gaze Poor left conjugate gaze Dysarthria Dysarthria Spatial – perceptual disorientation Spatial – perceptual disorientation Denies deficits, Impulsive, Poor judgment, Short attention spanDenies deficits, Impulsive, Poor judgment, Short attention span

Manifestations & Complications Manifestations & Complications by Body Systemby Body System

IntegumentIntegument– Pressure ulcersPressure ulcers

RespiratoryRespiratory– Respiratory center damageRespiratory center damage– Airway obstructionAirway obstruction– Decreased cough abilityDecreased cough ability

GIGI– DysphagiaDysphagia– ConstipationConstipation– Stool impactionStool impaction


MusculoskeletalMusculoskeletal– Hemiplegia or Hemiplegia or

hemiparesishemiparesis– ContracturesContractures– Bony ankylosisBony ankylosis– Disuse atrophyDisuse atrophy– Dysarthria - word Dysarthria - word

formationformation– Dysphagia – swallowDysphagia – swallow– Apraxia – complex Apraxia – complex

movements movements – Flaccidity/spasticityFlaccidity/spasticity

GUGU– IncontinenceIncontinence– FrequencyFrequency– UrgencyUrgency– Urinary retentionUrinary retention– Renal calculiRenal calculi


NeurologicalNeurological– HyperthermiaHyperthermia– Neglect syndromeNeglect syndrome– SeizuresSeizures– Agnosias (familiar obj)Agnosias (familiar obj)

– Communication Communication deficitsdeficits

Aphasia (expressive, Aphasia (expressive, receptive, global)receptive, global)

AgraphiaAgraphia

– Visual deficitsVisual deficitsHomonymous Homonymous hemianopiahemianopia

DiplopiaDiplopia

Decreased acuityDecreased acuity

Decreased blink reflex Decreased blink reflex


Neurological (cont.)Neurological (cont.)– Cognitive changesCognitive changes

Memory lossMemory loss

Short attention Short attention spanspan

Poor judgmentPoor judgment

DisorientationDisorientation

Poor problem-Poor problem-solving abilitysolving ability

– Behavioral Behavioral changeschanges

Emotional labilityEmotional lability

Loss of Loss of inhibitionsinhibitions

FearFear

HostilityHostility

Nursing Nursing Diagnoses/InterventionsDiagnoses/Interventions

Ineffective Tissue PerfusionIneffective Tissue Perfusion– Goal is to maintain cerebral perfusionGoal is to maintain cerebral perfusion

Monitor respiratory statusMonitor respiratory status

Auscultate, monitor lung soundsAuscultate, monitor lung sounds

Suction as needed – Suction as needed – increases ICPincreases ICP

Place in side-lying position (secretions)Place in side-lying position (secretions)

OO22 as needed/prescribed as needed/prescribed

Assess LoC, other neuro vital signsAssess LoC, other neuro vital signs

NIH Stroke Scale NIH Stroke Scale

Glasgow Coma Scale – Eyes, Verbal, & MotorGlasgow Coma Scale – Eyes, Verbal, & Motor


Ineffective Tissue Perfusion (cont)Ineffective Tissue Perfusion (cont)

Monitor strength/reflexesMonitor strength/reflexes

Assess for HA, sluggish pupils, posturingAssess for HA, sluggish pupils, posturing

Monitor cardiac statusMonitor cardiac status

Monitor I&O’sMonitor I&O’s– Can get DI as result of pituitary gland damageCan get DI as result of pituitary gland damage

Monitor seizure activityMonitor seizure activity


Impaired Physical MobilityImpaired Physical Mobility– Goal is to maintain and improve functioningGoal is to maintain and improve functioning

Active ROM for unaffected extremitiesActive ROM for unaffected extremities

Passive ROM for affected extremities Passive ROM for affected extremities

Q2 hr turnsQ2 hr turns

Assess for thrombophlebitisAssess for thrombophlebitis

Confer with PT for movement and positioning Confer with PT for movement and positioning techniques for each stage of rehabtechniques for each stage of rehab


Impaired Physical MobilityImpaired Physical MobilityFlaccidity & spasticity Flaccidity & spasticity

Meds used to treat spasticity:Meds used to treat spasticity:

Kemstro or Lioresal (baclofen) Kemstro or Lioresal (baclofen) Valium (diazepam) Valium (diazepam)

Dantrium (dantrolene sodium) Dantrium (dantrolene sodium)

Zanaflex (Zanaflex (tizanidine hydrochloridetizanidine hydrochloride) )

New drugs being tried – New drugs being tried – – Neurontin (Neurontin (GabapentinGabapentin) & ) & Botox (Botox (botulinum toxin)botulinum toxin)


Self-Care DeficitSelf-Care Deficit– Goals are to promote functional ability, Goals are to promote functional ability,

increase independence, improve self-esteemincrease independence, improve self-esteemEncourage use of unaffected arm in ADLsEncourage use of unaffected arm in ADLs

Self-dressing (using unaffected side to dress Self-dressing (using unaffected side to dress affected side first)affected side first)

Sling or support for affected armSling or support for affected arm

Confer with OT for techniques to promote return to Confer with OT for techniques to promote return to independenceindependence

Nursing Diagnoses/InterventionsNursing Diagnoses/Interventions

Impaired Verbal CommunicationImpaired Verbal Communication– Goal is to increase communicationGoal is to increase communication

Speak in normal tones unless there is a documented Speak in normal tones unless there is a documented hearing impairmenthearing impairment

Allow adequate time for responsesAllow adequate time for responses

Face center client when speaking, speak simply and Face center client when speaking, speak simply and enunciate wordsenunciate words

If you don’t understand what the client is saying, let If you don’t understand what the client is saying, let them know, and have them try againthem know, and have them try again


Impaired Verbal Communication (cont)Impaired Verbal Communication (cont)Try alternate method of communication if neededTry alternate method of communication if needed

– Writing, computerized boards, etcWriting, computerized boards, etc

Allow client anger and frustration at loss of Allow client anger and frustration at loss of previous functioningprevious functioning

Allow client to touch (hands, arms), may be the Allow client to touch (hands, arms), may be the only way of expressing (comfort, etc)only way of expressing (comfort, etc)

If client has visual disturbances:If client has visual disturbances:– During initial phase of recovery, position where client can During initial phase of recovery, position where client can

easily see you; in later stages, client can be directed to easily see you; in later stages, client can be directed to adjust position for visual contactadjust position for visual contact


Impaired Urinary Elimination & Risk for Impaired Urinary Elimination & Risk for ConstipationConstipation– Goal is to return to normal functioning if Goal is to return to normal functioning if

possible or to increase/achieve independence possible or to increase/achieve independence in maintaining bodily functions.in maintaining bodily functions.

Bladder training programBladder training programKegel exercisesKegel exercisesEncourage fluids, high fiber dietEncourage fluids, high fiber dietIncrease physical activities as toleratedIncrease physical activities as toleratedAssist client to use toilet at same time each dayAssist client to use toilet at same time each day


Impaired SwallowingImpaired Swallowing– Goal is safety, adequate nutrition, and Goal is safety, adequate nutrition, and

hydrationhydrationPosition client upright, using **pureed – less often Position client upright, using **pureed – less often ** or finely chopped soft foods** or finely chopped soft foodsHot or cold food or thickened liquidsHot or cold food or thickened liquidsTeach client to put food behind teeth on unaffected Teach client to put food behind teeth on unaffected side and tilt head backwardsside and tilt head backwardsCheck for food pockets, especially on affected sideCheck for food pockets, especially on affected sideHave suctioning equipment at bedsideHave suctioning equipment at bedsideMinimize distractions while eatingMinimize distractions while eatingNever leave client with food etc. in mouthNever leave client with food etc. in mouth

AneurysmAneurysm

AneurysmAneurysm

Incidence & PrevalenceIncidence & Prevalence– 5 million North Americans5 million North Americans– ~30,000/year will have aneurysm rupture~30,000/year will have aneurysm rupture– Most common in 30-60 yr oldsMost common in 30-60 yr olds

EtiologyEtiology– UnknownUnknown– Theories:Theories:

Developmental defect in vessel wallDevelopmental defect in vessel wall

Degeneration of wall from vessel disease/damageDegeneration of wall from vessel disease/damage

Chronic untreated hypertensionChronic untreated hypertension

AneurysmAneurysm

PathophysiologyPathophysiology– Circle of Willis, bifurcations Circle of Willis, bifurcations

and branchesand branches– 85% located anteriorly85% located anteriorly– Tend to enlarge with timeTend to enlarge with time– Tend to rupture from Tend to rupture from

dome, which forces blood dome, which forces blood into subarachnoid space; into subarachnoid space; or tissue, ventricles, or tissue, ventricles, subdural spacesubdural space

TypesTypes– BerryBerry– SaccularSaccular– FusiformFusiform– DissectingDissecting

"fusiform" aneurysm

is an outward

bulging of the blood

vessel wall in all

directions.

"saccular" aneurysm

is a formation of a

sac or pouch on one

side of the blood

vessel wall.

An alternative to open surgery is the minimally invasive procedure known as endovascular embolization. With this technique, a catheter is placed into the large artery of the leg, and with x-ray guidance is advanced until it reaches the aneurysm site. The aneurysm is then "packed" with tiny thread-like coils that are passed through the catheter into the aneurysm. The coils and the body's reaction to them effectively seal off the aneurysm. In contrast to conventional open surgery, this technique allows the aneurysm to be treated from the inside of the vessel, thus the name "endovascular" surgery. Endovascular embolization can be used to treat aneurysms in many locations and has been shown to be particularly useful in treating aneurysms that are very difficult or impossible to reach by conventional neurosurgical techniques.

AneurysmAneurysm

Until rupture, asymptomaticUntil rupture, asymptomatic– Unless large which can cause pressure on adjacent Unless large which can cause pressure on adjacent

tissues tissues – Can have prodromal symptomsCan have prodromal symptoms

Once rupturesOnce ruptures– Sudden explosive HASudden explosive HA– LoCLoC– N/VN/V– Stiff neckStiff neck– PhotophobiaPhotophobia– Cranial nerve deficitsCranial nerve deficits– Stroke symptomsStroke symptoms– Pituitary malfunctions (changes in ADH)Pituitary malfunctions (changes in ADH)

AneurysmAneurysmComplicationsComplications– RebleedingRebleeding

First day (first 2 hours most common)First day (first 2 hours most common)

7-10 days after clot breakdown7-10 days after clot breakdown

Will have similar manifestations as initial rupture, but may Will have similar manifestations as initial rupture, but may have new neurologic symptomshave new neurologic symptoms

– VasospasmVasospasm3-10 days (with most between 3 to 5 days)3-10 days (with most between 3 to 5 days)

Narrows lumen of vessels leading to ischemia and infarctionNarrows lumen of vessels leading to ischemia and infarction

May have focal deficits or LoCMay have focal deficits or LoC

– HydrocephalusHydrocephalusMay be result of obstruction of CSF reabsorptionMay be result of obstruction of CSF reabsorption

Causes Causes ICP ICP

Will have decreasing LoCWill have decreasing LoC

AneurysmAneurysm

Diagnostic TestsDiagnostic Tests– CTCT– LPLP– Bilat carotid & vertebral cerebral angiographyBilat carotid & vertebral cerebral angiography

MedicationsMedications– AmicarAmicar (aminocaproic acid) - fibrinolysis inhibitor (aminocaproic acid) - fibrinolysis inhibitor– Calcium channel blockers - Nimotop (nimodipine) Q 4 Calcium channel blockers - Nimotop (nimodipine) Q 4

hr. X 21 days)hr. X 21 days)– AnticonvulsantsAnticonvulsants– Stool softenersStool softeners– AnalgesicsAnalgesics

AneurysmAneurysm

SurgerySurgery

– ClippingClipping

– Wrapping Wrapping

– CoilsCoils

AneurysmAneurysm

Nursing Diagnoses/InterventionsNursing Diagnoses/Interventions– Ineffective Tissue Perfusion (Cerebral)Ineffective Tissue Perfusion (Cerebral)

Quiet dark roomQuiet dark room

Monitor VS/neuro statusMonitor VS/neuro status

Limit visitorsLimit visitors

Elevate HOB 30-45 degreesElevate HOB 30-45 degrees

Promote relaxationPromote relaxation

Prevent constipation/strainingPrevent constipation/straining

Avoid positions & activity that Avoid positions & activity that ICP ICP

AneurysmAneurysm

Complications – post microsurgical Complications – post microsurgical clipping or endovascular coiling clipping or endovascular coiling – Early seizuresEarly seizures– Acute hydrocephalusAcute hydrocephalus– Dilutional hyponatremia from inappropriate Dilutional hyponatremia from inappropriate

ADH or excess IV fluidsADH or excess IV fluids– Respiratory complications – pneumoniaRespiratory complications – pneumonia– Cardiopulmonary with catecholamine surge:Cardiopulmonary with catecholamine surge:

IICP; elevated pulse, B/P, temp alterations; mildly IICP; elevated pulse, B/P, temp alterations; mildly elevated cardiac enzymes, decreased ejection elevated cardiac enzymes, decreased ejection fraction; altered pupils, excessive salivation, fraction; altered pupils, excessive salivation, extension/decerebrate posturingextension/decerebrate posturing

Arteriovenous MalformationArteriovenous Malformation(AVM)(AVM)

Arteriovenous MalformationArteriovenous Malformation(AVM)(AVM)

Incidence & PrevalenceIncidence & Prevalence– Account for 2% of all strokesAccount for 2% of all strokes– Manifestations occur before 40 yrs of ageManifestations occur before 40 yrs of age– Congenital lesionCongenital lesion

90% are in cerebral hemispheres90% are in cerebral hemispheres

10% are in cerebellum and brainstem10% are in cerebellum and brainstem

AVMAVM

PathophysiologyPathophysiology– Tangle of dilated Tangle of dilated

arteries and veinsarteries and veinsBlood flow bypasses Blood flow bypasses capillary bedcapillary bedBlood going directly Blood going directly from arteries into veins from arteries into veins increases risk of increases risk of bleeding or rupture of bleeding or rupture of vesselvessel

Diagnostic TestsDiagnostic Tests– Same as for Same as for

intracranial aneurysmintracranial aneurysm

This network of abnormal connections represents the "nidus". Arteriovenous malformation of the brain presents later in childhood or, more frequently, in adults in the second to third decade of life. AVMs present with seizures, hemorrhage, progressive neurological dysfunction or headaches. On occasion, these lesions are found incidentally during an MRI or CT scan of the brain obtained for other reasons

AVMs can be difficult to treat and often require a multidisciplinary approach to therapy. At the Center for Endovascular Surgery, embolization is the first line of attack in the management of this condition. Embolization for arteriovenous malformation may be done as the sole form of treatment or in preparation for microsurgical resection or radiation therapy. For patients with AVMs that cannot be cured due to the size or location of their lesion, palliative embolization can improve the patient's quality of life and diminish symptoms such as headaches, seizures or other problems.

AVMAVM

TreatmentTreatment– Surgery if accessibleSurgery if accessible– Embolization (large AVMs)Embolization (large AVMs)– Radiation or Laser therapyRadiation or Laser therapy– Gamma Knife/Laser knifeGamma Knife/Laser knife

Nursing CareNursing Care– If no hemorrhage: teaching should focus on ways to If no hemorrhage: teaching should focus on ways to

avoid avoid ICP ICP– If hemorrhage: same as client with hemorrhagic If hemorrhage: same as client with hemorrhagic

strokestroke

Case StudyCase Study

RB is an 80 yr old female. Upon awakening one RB is an 80 yr old female. Upon awakening one morning, her husband noted she had slurred morning, her husband noted she had slurred speech, R facial droop, and disorientation. A CT speech, R facial droop, and disorientation. A CT scan at the hospital confirmed intracranial scan at the hospital confirmed intracranial hemorrhage. Because of bleed location, surgery hemorrhage. Because of bleed location, surgery was not possible. The R facial droop progressed was not possible. The R facial droop progressed to totally flaccid R side over the next few days. to totally flaccid R side over the next few days. 10 days after initial symptoms, RB has been 10 days after initial symptoms, RB has been transferred to your rehab unit. She still has some transferred to your rehab unit. She still has some confusion, memory difficulties, slurred speech, confusion, memory difficulties, slurred speech, problems with swallowing, and R sided problems with swallowing, and R sided weakness.weakness.

Resourceswww.stroke.org -- National Stroke Association (800-787-6537) www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke (800-352-9424) www.naric.com -- National Rehabilitation Information Center (8003462742) www.aphasia.org -- National Aphasia Association (800-922-4622) www.aan.com -- American Academy of Neurology www.dynamic-living.com -- Daily living products www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf -- NIH stroke scoring system www.strokecenter.org/trials -- Find a clinical trial on stroke

End of CVA, Aneurysm End of CVA, Aneurysm and AVM’sand AVM’s

Documents

Stroke Charlene Morris, RN, MSN With grateful acknowledgment to Marnie Quick, RN, MSN, CNRN