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Cerebrovascular Accident (CVA) aka “Brain Attack”

Cerebrovascular Accident (CVA) aka “Brain Attack”. Chris Puglia, MSN, RN, CEN. Objectives. Define cerebrovascular accident and associated terminology Discuss related pathophysiology and presentation of various types of stroke

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Cerebrovascular Accident (CVA) aka “Brain Attack”

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  1. Cerebrovascular Accident (CVA)aka “Brain Attack” Chris Puglia, MSN, RN, CEN

  2. Objectives • Define cerebrovascular accident and associated terminology • Discuss related pathophysiology and presentation of various types of stroke • Discuss etiology, risk factors, diagnostics, management, and outcomes of stroke • Review case studies and nursing diagnoses, interventions, and goals

  3. Definition • Cerebral Vascular Accident (CVA), Stroke or “brain attack” is an acute CNS injury that results in neurologic S/S brought on by a reduction or absence of perfusion to a territory of the brain. The disruption in flow is from either an occlusion (ischemic) or rupture (hemorrhagic) of the blood vessel.

  4. Incidence & Prevalence • Third leading cause of death in the USA • 795,000+ people/year • 175,000 die within one year (25%) • Leading cause of long-term disabilities • 5.5 million survivors (USA) • 15 to 30 % live with permanent disability

  5. Definitions • Cerebrovascular Accident • Ischemic Stroke • Thrombotic • Embolic • Lacunar infarct • TIA • Hemorrhagic Stroke • ICH • SAH

  6. Thrombotic Stroke • Occlusion of large cerebral vessel (blood clot) • Older population • Sleeping/resting • Rapid event, but slow progression (usually reach max deficit in 3 days)

  7. Embolic Stroke • Embolus becomes lodged in vessel and causes occlusion • Bifurcations are most common site • Sudden onset with immediate deficits • Embolysis • Hemorrhagic Transformation

  8. Lacunar Strokes - 20% of all stokes • Minor deficits • Paralysis and sensory loss • Lacune • Small, deep penetrating arteries • High incidence: • Chronic hypertension • Elderly • DIC

  9. Transient Ischemic Attack • Warning sign for stroke • Brief localized ischemia • Common manifestations: • Contralateral numbness/ weakness of hand, forearm, corner of mouth • Aphasia • Visual disturbances- blurring • Deficits last less than 24 hours (usually less than 1 or 2 hrs) • Can occur due to: • Inflammatory artery disorders • Sickle cell anemia • Atherosclerotic changes

  10. Hemorrhagic Stroke Definitions • Intracerebral hemorrhage • Intracranial hemorrhage • Parenchymal hemorrhage • Intraparenchymal hematoma • Contusion • Subarachnoid hemorrhage

  11. Hemorrhagic Stroke • Rupture of vessel • Sudden • Fatal • Causes: • HTN • Trauma • Varied manifestations

  12. Hemorrhagic Stroke • Intracerebral Hemorrhage (ICH) • Subarachnoid Hemorrhage (SAH)

  13. PathophysiologyHemorrhagic Stroke • Changes in vasculature • Tear or rupture • Hemorrhage • Decreased perfusion • Clotting • Edema • Increased intracranial pressure • Cortical irritation

  14. PhysiologyNormal Cerebral Blood Flow • Oxygen • Glucose • 20% of Cardiac Output / Oxygen • Arterial supply to the brain: • Internal carotid (anteriorly) • Vertebral arteries (posteriorly) • Venous drainage • 2 sets of veins - venous plexuses • Dural sinuses to internal jugular veins • Sagittal sinus to vertebral veins • No valves, depend on gravity and venous pressure gradient for flow

  15. Risk Factors NON-MODIFIABLE MODIFIABLE Hypertension Diabetes mellitus Heart disease A-fib Asymptomatic carotid stenosis Hyperlipidemia Obesity Oral contraceptive use Heavy alcohol use Physical inactivity Sickle cell disease Smoking Procedure precautions • Age • 2/3 over 65 • Gender • M=F • Female>fatality • Race • AA > hispanics, NA • Asians > hem • Heredity • Family history • Previous TIA/CVA

  16. EtiologyIschemic Stroke Embolism Prothrombotic states Hemostatic regulatory protein abnormalities Antiphospholipid antibodies Hep cofactor II • Atrial fib • Sinoatrial D/O • Recent MI • Endocarditis • Cardiac tumors • Valvular D/O • Patent foramen ovale • Carotid/basilar artery stenosis • Atherosclerotic lesions • Vasculitis

  17. Etiology Hemorrhagic Stroke • Chronic HTN** • Cerebral Amyloid Angiopathy* • Anticoagulation* • AVM • Ruptured aneurysm (usually subarachnoid) • Tumor • Sympathomimetics • Infection • Trauma • Transformation of ischemic stroke • Physical exertion, Pregnancy • Post-operative

  18. Aneurysm • Localized dilation of arterial lumen • Degenerative vascular disease • Bifurcations of circle of Willis • 85% anterior • 15% posterior

  19. AneurysmSubarachnoid Hemorrhage • SAH • Mortality 70% • 97% HA • Nuchal rigidity • Fever • Photophobia • Lethargy • Nausea • Vomiting

  20. Aneurysm/SAH • Complications • HCP (hydrocephalus) • Vasospasm • Triple H Therapy • HTN • Hemodilution • Hypervolemia • Surgical treatment • Clip • Coil • Surgical Coil • INR

  21. Nursing Management • Assessment • Monitoring • BP • TCDs • CBC • Preventing complications • Bowel program • DVT prophylaxis • Siezure prophylaxis • Psychological support • Discharge planning

  22. Arteriovenous Malformations • AVM • Tangled mass of arteries and veins • Seizure or ICH

  23. Treatment AVM • Endovascular • Neurosurgery • Radiosurgery

  24. Presentation • Sudden onset • Focal neurological deficit • Progresses over minutes to hours • HA, N/V, <<LOC, HTN • Depends on location

  25. Stroke Symptoms include: • SUDDEN numbness or weakness of face, arm or leg • SUDDEN confusion, trouble speaking or understanding. • SUDDEN trouble with vision • SUDDEN trouble walking, dizziness, loss of balance or coordination • SUDDEN severe HA

  26. Manifestationsby Vessel • Vertebral Artery • Pain in face, nose, or eye • Numbness and weakness of face (involved side) • Gait disturbances • Dysphagia • Dysarthria (motor speech)

  27. Manifestationsby Vessel • Internal Carotid Artery • Contralateral paralysis (arm, leg, face) • Contralateral sensory deficits • Aphasia (dominant hemisphere involvement) • Apraxia (motor task), • Agnosia (obj. recognition), • Unilateral neglect (non-dominant hemisphere involvement) • Homonymous hemianopia

  28. Manifestations & Complications by Body System • Neurological • Hyperthermia • Neglect syndrome • Seizures • Agnosias (familiar obj) • Communication deficits • Aphasia (expressive, receptive, global) • Agraphia • Visual deficits • Homonymous hemianopia • Diplopia • Decreased acuity • Decreased blink reflex

  29. Manifestations & Complications by Body System • Neurological (cont.) • Cognitive changes • Memory loss • Short attention span • Poor judgment • Disorientation • Poor problem-solving ability • Behavioral changes • Emotional lability • Loss of inhibitions • Fear • Hostility

  30. Manifestations & Complications by Body System • Musculoskeletal • Hemiplegia or hemiparesis • Contractures • Bony ankylosis • Disuse atrophy • Dysarthria - word formation • Dysphagia – swallow • Apraxia – complex movements • Flaccidity/spasticity • GU • Incontinence • Frequency • Urgency • Urinary retention • Renal calculi

  31. Manifestations & Complications by Body System • Integument • Pressure ulcers • Respiratory • Respiratory center damage • Airway obstruction • Decreased cough ability • GI • Dysphagia • Constipation • Stool impaction

  32. Initial Stroke Assessment/Interventions • Neurological assessment • Call “Stroke Alert” Code • Ensure patient airway • VS • IV access (What size?) • Maintain BP within parameters (check MAP) • Position head midline • HOB 30 (if no shock/injury) • CT, blood work, data collection • NIH Stroke Scale • Anticipate thrombolytic therapy for ischemic stroke

  33. NIH Stroke Scale Score • Standardized method • measures degree of stroke r/t impairment and change in a patient over time. • Helps determine if degree of disability merits treatment 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 rehabilitation interventions. • Measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language not measured by Glasgow coma scale.

  34. NIH Stroke Scale Handout • Current NIH Stroke Score guidelines for measuring stroke severity: Points are given for each impairment. • 0= no stroke • 1-4= minor stroke • 5-15= moderate stroke • 15-20= moderate/severe stroke • 21-42= severe stroke • A maximal score of 42 represents the most severe and devastating stroke.

  35. Acute Stroke Times

  36. Question • A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipated that the health care provider will request a • A. CT scan. • B. lumbar puncture. • C. cerebral angiogram. • D. PET scan.

  37. Diagnostics Tests for the Emergent Evaluation of the Patient with Acute Ischemic Stroke • CT head (-) • Electrocardiogram • Chest x-ray • Hematologic studies (complete blood count, platelet count, prothrombin time, partial thromboplastin time) • Serum electrolytes • Blood glucose • Renal and hepatic chemical analyses • National Institute of Health Scale (NIHSS) score

  38. Diagnostics Ischemic Stroke Hemorrhagic Stoke

  39. Medical Management • BP • MAP • CPP • Factor VII, Vit K, FFP • ICP • HOB • Sedation • Osmotherapy • Hyperventilation • Paralytics • Fluid management • euvolemia • Seizure prophylaxis • Keppra • Dilantin • Sedation • Body temperature • PT/OT/ST • DVT prophylaxis

  40. Treatment Ischemic Hemorrhagic Medical management Decompression Craniotomy Craniectomy • Medical management • tPA • Endovascular • Carotid endarectomy • Merci clot removal • Clot removal PT/OT/ST REHABILITATION

  41. Medications • Anti-coagulants – A fib & TIA • Antithrombotics • Calcium channel blockers – Nimotop (nimodipine) • Corticosteroids ??? • Diuretics – Mannitol, Lasix (Furosemide) • Anticonvulsants – Dilantin (phenytoin) or Cerebyx (Fosphenytoin Sodium Injection) • Thrombolytics - tPA (recombinant tissue plasminogen activator)

  42. Medications • Thrombolytics Recombinant Alteplase (rtPA) Activase, Tissue plasminogen activator • Treatment must be initiated promptly after CT to R/O bleed • Systemic within 3 hours of onset of symptoms • Intra-arterial within 6 hours of symptoms • Some exclusions: • Seizure at onset • Subarachnoid hemorrhage • Trauma within 3 months • History of prior intracranial hemorrhage • AV malformation or aneurysm • Surgery 14 days, pregnancy, • Cardiac cath. 7 days

  43. Neurosurgical Management • Craniotomy • Craniotomy Procedure • Craniectomy

  44. Neurosurgical Management • EVD placement • ICP monitor placement

  45. Recommendations for Surgical Treatment of ICH • Nonsurgical candidates • Small hemorrhage • Minimal deficit • GCS </= 4 (unless brain stem compression) • Loss of brainstem fxn • Severe coagulopathy • Basal ganglion or thalamic • Surgical candidates • >3cm • Neuro deficit • Brain stem compression • HCP • Aneurysm, AVM, cavernous hemangioma • Young with mod/large lobar hemorrhage and clinical deterioration

  46. Question • A carotid endarectomy is being considered as treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery • A. is used to restore blood circulation to the brain following an obstruction of a cerebral artery. • B. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery. • C. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke. • D. is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation.

  47. Standing Orders • Per facility policy

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