Management of Patients with Cerebrovascular Disorders

1. Management of Patients with CVD Clinical Instructor: DAISE JEAN L. MEOMEO, PhRN, USRN

2. Learning Content What is a stroke? Risk factors Types of stroke Diagnosis Symptoms Treatment

3. What is a Stroke? A stroke is when the blood supply to part of the brain is cut off. This causes the cells in this area of the brain to die off.

4. Types of Strokes Ischemic Stroke Hemorrhagic Stroke Occurs when the blood supply is cut off, due to a clot forming within a blood vessel in the brain. Occurs when a blood vessel bursts and bleeds reducing the blood supply to the brain.

5. Symptoms Arm or leg weakness Speech changes Facial weakness Visual changes

6. Risk Factors • Raised cholesterol • High blood pressure • Uncontrolled diabetes • Excessive alcohol • Smoking • Atrial fibrillation

7. Diagnosis Checking for irregular heartbeat Blood tests for cholesterol CT scans MRI scans

8. ISCHEMIC STROKE • An ischemic stroke occurs when blood flow to a part of the brain is blocked, leading to reduced oxygen and nutrient delivery, and causing brain cell death within minutes. • Most common type of stroke (~87% of all strokes). • Caused by thrombosis (clot forming in a brain vessel) or embolism (clot traveling from elsewhere, often the heart).

9. ISCHEMIC STROKE • Risk factors are modifiable and non-modifiable: • A. Non-modifiable • Age (↑ risk > 55 years old) • Sex (men slightly higher risk, but women more likely to die from stroke) • Race/ethnicity (African, Hispanic, and Asian descent have higher incidence) • Family history of stroke

10. ISCHEMIC STROKE • B. Modifiable • Hypertension (most important) • Diabetes mellitus • Atrial fibrillation and other heart diseases • Hyperlipidemia • Smoking • Physical inactivity • Obesity • Excessive alcohol intake • Poor diet (high salt, high saturated fat)

11. ISCHEMIC STROKE • 3. Laboratory & Diagnostic Tests • Purpose: Confirm stroke type, determine cause, guide treatment. • A. Imaging • CT scan (non-contrast) – Gold standard initial test; rules out hemorrhage before thrombolysis. • MRI brain – More sensitive for early ischemic changes. • CT/MR angiography – Detects vessel blockages.

12. ISCHEMIC STROKE • B. Blood Tests • CBC (baseline; check for anemia, infection) • Electrolytes, renal function (safe use of medications) • Blood glucose (hypo/hyperglycemia can mimic stroke) • Coagulation profile (PT, aPTT, INR) • Lipid profile • Cardiac enzymes (if cardiac source suspected)

13. ISCHEMIC STROKE • C. Cardiac Work-up • ECG (look for atrial fibrillation, MI) • Echocardiogram (check for cardiac emboli)

14. ISCHEMIC STROKE • 4. Clinical Manifestations • Depend on the area of brain affected and size of infarct. Sudden onset is typical. • Motor deficits: Weakness or paralysis (hemiplegia), facial droop. • Sensory deficits: Numbness, tingling, loss of sensation. • Speech/language problems: • Aphasia (expressive, receptive, or global) • Dysarthria (slurred speech) • Visual changes: Loss of vision in one or both eyes, diplopia. • Cognitive changes: Confusion, poor judgment. • Balance/coordination problems: Ataxia, dizziness. • FAST symptoms: Face droop, Arm weakness, Speech difficulty, Time to act.

15. ISCHEMIC STROKE • 5. Medical Management • Goal: Restore blood flow to the brain ASAP, prevent further damage. • A. Emergency Care • Maintain ABCs (Airway, Breathing, Circulation) • Oxygen if O₂ sat < 94% • Monitor neuro status (NIHSS scale)

16. ISCHEMIC STROKE • B. Specific Treatment • Thrombolytic therapy: IV alteplase (tPA) within 4.5 hours of symptom onset (if eligible). • Endovascular thrombectomy: Within 6–24 hrs for large-vessel occlusions. • Antiplatelets: Aspirin within 24–48 hrs (unless tPA given). • Blood pressure management: Allow permissive hypertension (unless > 220/120 mmHg or > 185/110 mmHg if tPA candidate). • Control blood sugar: Maintain 140–180 mg/dL.

17. ISCHEMIC STROKE • 6. Surgical Management • Carotid endarterectomy: Removes plaque from carotid artery. • Carotid artery stenting: Keeps narrowed artery open. • Extracranial–intracranial bypass: Rare; connects artery outside skull to one inside to restore flow.

18. ISCHEMIC STROKE • 7. Nursing Management • A. Acute Phase • Position HOB 30° to reduce ICP and improve venous drainage. • Maintain airway, suction PRN. • Assess swallow before oral intake (prevent aspiration). • Frequent neuro checks. • Prevent complications: DVT prophylaxis, skin care, reposition every 2 hours. • Maintain safety: Fall precautions, bed in low position. • Manage elimination: Bladder training, prevent constipation.

19. ISCHEMIC STROKE • B. Rehabilitation Phase • Collaborate with PT, OT, and speech therapy. • Encourage use of affected side (avoid learned non-use). • Support emotional needs of patient and family. • Teach energy conservation and assistive device use.

20. ISCHEMIC STROKE • 8. Prevention • Primary prevention (for those without stroke yet): • Control BP, diabetes, cholesterol. • Quit smoking. • Healthy diet, regular exercise. • Secondary prevention (for those with previous TIA/stroke): • Antiplatelet drugs (aspirin, clopidogrel). • Anticoagulants for atrial fibrillation. • Carotid intervention if indicated.

21. ISCHEMIC STROKE • Possible Complications • Increased intracranial pressure (ICP) • Hemorrhagic transformation of infarct • Seizures • Pneumonia (due to aspiration) • DVT and pulmonary embolism • Pressure ulcers • Depression and post-stroke cognitive decline

22. ISCHEMIC STROKE Key Signs & Symptoms of Ischemic Stroke (Remember: FAST + BE FAST) F – Face drooping on one side A – Arm weakness or numbness (especially one side) S – Speech difficulty (slurred, incoherent, unable to speak) T – Time to call emergency services immediately Additional BE FAST: B – Balance loss or sudden dizziness E – Eyes – sudden vision changes (loss, double vision)

23. Treatment Physical therapies Thrombolysis & thrombectomy Psychological therapies Medication

24. 1. Immediate/Emergency Management (First Hours) • Goals: Preserve life, prevent further brain damage, and reduce complications. • A. Initial Assessment (ABC) • Airway: Ensure patency; suction if needed; consider intubation if GCS ≤ 8. • Breathing: Administer oxygen if O₂ sat < 94%. • Circulation: Monitor BP—avoid rapid lowering unless > 220/120 mmHg (ischemic) or per protocol for hemorrhagic. • Rapid Neurological Assessment: NIH Stroke Scale (NIHSS), GCS.

25. 1. Immediate/Emergency Management (First Hours) • Goals: Preserve life, prevent further brain damage, and reduce complications. • B. Diagnostic Work-up • CT scan/MRI brain: Differentiate ischemic from hemorrhagic stroke (must be done before giving thrombolytics). • Blood tests: CBC, electrolytes, coagulation profile, blood glucose. • ECG: Rule out arrhythmias (e.g., atrial fibrillation).

26. 2. Specific Management According to Stroke Type • A. Ischemic Stroke • Thrombolytic therapy: • IV alteplase (tPA) within 4.5 hours of symptom onset if no contraindications. • Endovascular thrombectomy: Within 6–24 hours for large-vessel occlusions. • Antiplatelet therapy: Aspirin 160–325 mg within 24–48 hours (unless tPA given; then delay aspirin for 24 hrs). • Blood pressure control: Maintain perfusion; gradual lowering if necessary. • Blood glucose management: Keep 140–180 mg/dL.

27. 2. Specific Management According to Stroke Type • B. Hemorrhagic Stroke • Blood pressure reduction: Often to < 140 mmHg systolic. • Reversal of anticoagulation: Vitamin K, PCC, or specific antidotes (e.g., idarucizumab for dabigatran). • Neurosurgical intervention: For large hematomas or aneurysms. • ICP control: Elevate HOB 30°, osmotic agents (mannitol/hypertonic saline), avoid hypotonic fluids.

28. 3. Supportive & Nursing Care • Position: Head midline, HOB 30° to promote venous return and reduceICP. • Preventaspiration: Speech therapist evaluation; NPO until swallow assessed. • Maintain skin integrity: Frequent turning, pressure relief. • Prevent DVT: Early mobilization, compression devices (avoid anticoagulants in acute hemorrhagic stroke). • Monitor for complications: Increased ICP, seizures, infections.

29. 4. Rehabilitation Phase • Physical therapy for mobility and strength. • Occupational therapy for ADLs. • Speech therapy for communication/swallowing deficits. • Psychological support for depression and anxiety. • Patient and family education on home care and risk factor modification.

30. 5. Long-Term Prevention • Lifestyle: Smoking cessation, weight control, healthy diet (low salt, low fat), exercise. • Control comorbidities: Hypertension, diabetes, hyperlipidemia. • Medications: • Antiplatelets (aspirin, clopidogrel) for ischemic stroke. • Anticoagulation for atrial fibrillation (if ischemic stroke and no contraindication). • Regular follow-up with neurology and primary care.

31. 📌 Nursing Alert: Early recognition of stroke symptoms using FAST (Face drooping, Arm weakness, Speech difficulty, Time to callemergency services) is crucial for timely treatment.

32. 💡 Quick Mnemonic to Remember: • I-S-C-H-E-M-I-C • I – Interrupted blood flow • S – Shortage of oxygen/glucose • C – Cell energy failure • H – High calcium influx • E – Excitotoxicity (too much glutamate) • M – Main damage in core, some in penumbra • I – Inflammation • C – Cell death (infarction)

33. All About Hemorrhagic Strokes

34. 🧠 Hemorrhagic Stroke • 1. Overview • A hemorrhagic stroke happens when a blood vessel in the brain ruptures, causing bleeding into the surrounding brain tissue or spaces around the brain. • This bleeding increases intracranial pressure (ICP) and reduces blood flow to parts of the brain, leading to brain cell damage. • It accounts for 10–15% of all strokes but has a higher mortality rate than ischemic stroke.

35. 🧠 Hemorrhagic Stroke • TYPES: • Intracerebral hemorrhage (ICH) – bleeding directly into brain tissue. • Subarachnoid hemorrhage (SAH) – bleeding into the space between the brain and arachnoid membrane (often from a ruptured aneurysm).

36. 🧠 Hemorrhagic Stroke • 2. Risk Factors • Modifiable: • Uncontrolled hypertension (most common cause) • Smoking • Excessive alcohol intake • Drug use (e.g., cocaine, amphetamines) • Anticoagulant or antiplatelet overuse • High cholesterol, obesity, sedentary lifestyle

37. 🧠 Hemorrhagic Stroke • 2. Risk Factors • Non-modifiable: • Older age • Male sex • Family history of stroke or aneurysm • History of previous stroke or TIA

38. 3. Clinical Manifestations • Sudden onset (minutes to hours), symptoms depend on location & size of bleed: • Neurologic deficits: sudden weakness or numbness (usually one side) • Severe, sudden headache (“worst headache of my life” → common in SAH) • Nausea/vomiting • Decreased level of consciousness, confusion, or coma • Speech problems (aphasia, dysarthria) • Vision changes (blurred vision, double vision) • Seizures • Signs of ↑ ICP: headache, vomiting without nausea, papilledema, Cushing’s triad (↑ BP, ↓ HR, irregular breathing)

39. 4. Pathophysiology • Blood vessel rupture (due to high BP, aneurysm, trauma, AV malformation, or clotting disorder) • Bleeding into brain tissue or subarachnoid space • Mass effect & ↑ ICP – the pooled blood compresses nearby brain tissue • Reduced cerebral blood flow → ischemia in surrounding tissue • Inflammatory reaction – release of toxins from blood breakdown products damages neurons • Cerebral edema – worsens compression and injury • Secondary brain injury – from both pressure and lack of oxygen • If untreated → herniation, coma, death

40. Pathophysiology Flow Using BLEED • B – Vessel rupture → sudden onset bleeding. • L – Blood spills into brain or subarachnoid space. • E – Blood triggers inflammation & edema, compressing nearby tissue. • E – Swelling raises ICP, lowering cerebral perfusion. • D – Neurons die from pressure and lack of oxygen.

41. . Medical Management • Goals: Control bleeding, reduce ICP, prevent complications. • Stabilization (Airway, Breathing, Circulation – ABCs) • Blood pressure control – lower BP carefully to prevent further bleeding but maintain cerebral perfusion (e.g., IV antihypertensives: labetalol, nicardipine) • Reverse anticoagulation if patient is on blood thinners (vitamin K, fresh frozen plasma, protamine sulfate for heparin) • ICP management – head elevation 30°, osmotic diuretics (mannitol), hypertonic saline • Seizure prophylaxis (levetiracetam, phenytoin in selected cases) • Pain management • Nimodipine for SAH to prevent vasospasm • Strict bed rest in acute phase

42. Surgical Management • Craniotomy – open skull to remove hematoma, relieve pressure • Stereotactic aspiration – minimally invasive clot removal • Aneurysm clipping – clip base of aneurysm to stop bleeding • Endovascular coiling – place coils inside aneurysm to promote clotting and sealing • Decompressive craniectomy – remove part of skull to relieve swelling

43. 7. Prevention • Control blood pressure (most important) • Avoid smoking & excessive alcohol • Maintain healthy diet & regular exercise • Manage diabetes & cholesterol • Use anticoagulants carefully and under supervision • Regular check-ups for people with family history of aneurysms or AV malformations

44. 8. Complications • Increased intracranial pressure → brain herniation • Rebleeding (especially in SAH) • Vasospasm → delayed cerebral ischemia • Hydrocephalus (CSF flow blocked by blood) • Seizures • Long-term neurologic deficits (paralysis, speech problems, cognitive changes) • Coma or death

45. 🧠 Clinical Scenario – Hemorrhagic Stroke in the Hospital • Patient Profile • Name: Mr. Antonio R., 62 years old • Sex: Male • History: Long-standing uncontrolled hypertension, smoker for 30 years, occasional alcohol use • Allergies: None known • Meds: Not on regular antihypertensive therapy • Onset: At home, suddenly developed severe headache and right-sided weakness while watching TV; collapsed to the floor.

46. Arrival in ER • Chief Complaint: “Worst headache of my life,” followed by vomiting and confusion. • Vital Signs: • BP: 210/110 mmHg • HR: 58 bpm • RR: 20/min • Temp: 36.8°C • SpO₂: 95% on room air • Neuro Exam: • GCS: 11 (E3, V3, M5) • Pupils: Left 3 mm reactive, right 3 mm sluggish • Motor: Weakness in right arm and leg (3/5 strength) • Speech: Slurred • Other: Nausea, projectile vomiting noted

47. Diagnostics • CT Scan: Left basal ganglia hemorrhage with mild intraventricular extension • Labs: Normal coagulation profile, CBC WNL • ICU Admission • Priority Nursing Problems: • Risk for increased intracranial pressure (ICP) related to cerebral bleeding and edema • Impaired physical mobility related to neuromuscular impairment • Risk for aspiration related to decreased LOC

48. Immediate Medical Management • Admit to ICU for close neuro monitoring • BP control with IV nicardipine drip (target systolic BP 140–160 mmHg) • Head of bed elevated 30° to promote venous drainage • Mannitol IV bolus to reduce cerebral edema • Seizure prophylaxis with IV levetiracetam • NPO until swallow evaluation • Neurosurgical team consult for possible craniotomy if bleed expands

50. Possible Complications to Watch For • Rebleeding (sudden neuro decline, headache spike) • Increased ICP → herniation (Cushing’s triad: ↑ BP, ↓ HR, irregular respirations) • Hydrocephalus (enlarged ventricles on CT, worsening LOC) • Seizures • Long-term disability