Neurological conditions Stroke Trigeminal neuralgia Myasthenia Gravis

What is a Stroke? Stroke is a brain injury that affects the brain’s blood supply Stroke is caused by interruption of blood flow to the brain When blood flow to the brain is interrupted, brain tissue is starved of oxygen and nutrients

A blood clot blocks a blood vessel in the brain Called an ischemic stroke Or a weakened blood vessel in or near the brain bursts and bleeds called hemorrhagic stroke A stroke happens when:

Types of stroke

Stroke signs & symptoms Sudden weakness or numbness on one side of the body Sudden confusion, trouble speaking or understanding Sudden vision changes in one or both eyes Sudden trouble walking, dizziness, or loss of balance Sudden, severe headache

 F=FACE drooping  A=ARM dangling  S=SLURRED SPEECH  T=TIME call 911 immediately Time is important because some treatments can only be given within 3-4 hours of the start of the first symptom Think FAST

Risk Factors stroke High blood pressure Irregular heart beat High Cholesterol Smoking Lack of exercise Obesity Excessive alcohol consumption High salt intake Stress diabetes

interruption of blood flow to the brain due to bleeding Usually rupture of a blood vessel in the brain due to an aneurysm 1. Hemorrhagic stroke

Hemorrhagic stroke

An aneurysm occurs when part of a blood vessel (artery) swells either the blood vessel is damaged or there is a weakness in the wall of the blood vessel What is an aneurysm?

Types of aneurysms Localized dilation of the wall of an artery or vein Berry aneurysms Fusiform aneurysms

 Aneurysm clipping or coiling  Surgical intervention to prevent sudden rupture of blood vessel  Doctor places catheter into groin and advances catheter into the brain  Pt is admitted to the hospital over night for monitoring and is discharged the next day Aneurysm treatment

 4:50  Nucleus Medical media  preview?ccat=all&clang=English&animationid=76477 Cerebral aneurysm Coiling video

Nursing care after procedure Monitor for bleeding after procedure Bleeding at site of puncture loss of pulse to extremity back pain decreased urinary output vomiting fast heart rate low blood pressure Neuro checks

 83 year old woman with complaints of dizziness while putting her eye drops in before bed  Came to the ER and the doctors ordered a CT angio gram (shows blood flow in the brain)  Found 3mm aneurysm  She had a coiling via right groin approach  After the procedure, she developed right groin bleeding upon arrival in ICU  Nurse immediately applied pressure to groin to stop bleeding Aneurysm Case Study

 Was monitored overnight for bleeding  No further bleeding  Right groin with small hematoma  Discharged home  Pt will follow up with Neurosurgeon in 2 weeks

2. Ischemic stroke Think of the blood supply to the brain as branches of a tree. The bigger branches supply more nutrients to the tree. So it is with the brain. If larger vessels are occluded, more of the brain can be damaged.

Causes of ischemic stroke Thrombotic stroke When a blood clot blocks an artery going to the brain. A build up of cholesterol inside the vessel wall can produce clots. Embolic stroke When a traveling blood clot is carried in the blood stream and blocks an artery inside or leading to the brain.

Treatment Reestablish blood flow Consider thrombolytic therapy if onset of witnessed symptoms is within 3 hours of time patient was last well Thrombolytic therapy is medicine to break up clot (TPA)  Remove the clot from the blood vessel (thrombectomy)

 Ischemic stroke video  2:30  Nucleus medical media  preview?ccat=all&clang=English&animationid=73789 Ischemic stroke video

44 year old man with history of high blood pressure, high cholesterol and diabetes began experiencing left sided weakness at 2:30pm Became non verbal CT scan showed thrombotic stroke TPA administered Agram was done, showed small clot still present, but no intervention needed Monitored overnight and discharged in morning Ischemic Stroke case study

 66 year old man with history of diabetes, high blood pressure, high cholesterol  Fell down stairs, came to ER, CT scan negative for bleeding in head  While in ER developed sudden right sided weakness and facial droop  Repeat head CT showed ischemic stroke, pt received TPA  Pt was monitored for bleeding overnight and had repeat head CT in morning Ischemic Stroke case study #2

 Pt was found to now have bleeding in brain  Was treated for acute ischemic stroke complicated by intracranial hemorrhage  While being monitored, pt was found to have an irregular heart rhythm  Cardiologist consulted and suggested that pt go home with cardiac monitoring to try and determine the cause of the stroke

Risk Factors stroke High blood pressure Irregular heart beat High Cholesterol Smoking Lack of exercise Obesity Excessive alcohol consumption High salt intake Stress diabetes

Trigeminal Neuralgia

 contact between a normal blood vessel and the trigeminal nerve  Aging  brain tumor  surgical injuries  Stroke  facial trauma Causes

 severe, shooting or jabbing pain that may feel like an electric shock  Sudden pain triggered by things such as touching the face, chewing, speaking and brushing teeth  pain lasts from a few seconds to several minutes  attacks lasting days, weeks, months or longer — some people have periods when they experience no pain  Constant aching, burning feeling  Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead  Pain affecting one side of the face at a time  Attacks that become more frequent and intense over time Symptoms

 The doctor usually will prescribe medications to lessen or block the pain signals sent to the brain.  Anticonvulsants: Medications that prevent seizures tegretol or dilantin  Antispasmodic agents: Muscle-relaxing agents baclofen Treatment

Surgical options microvascular decompression Relocating or removing blood vessels that are in contact with the trigeminal root. This eliminates pain most of the time, but pain can recur in some people. risks include decreased hearing, facial weakness, facial numbness or stroke

 surgeon directs a focused dose of radiation to the root of your trigeminal nerve.  The radiation reduces or eliminates pain  Relief occurs gradually and may take several weeks.  Gamma Knife radiosurgery is successful in eliminating pain for the majority of people.  If pain recurs, the procedure can be repeated. Surgical options Gamma knife radiosurgery

 ADD GAMMA VIDEO  2:30  Nucleus Medical  preview?ccat=all&clang=English&animationid=78926 Gamma knife Video

Myasthenia Gravis

 chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal muscles of the body.  The muscle weakness increases during periods of activity and improves after periods of rest. What is Myasthenia Gravis? grave muscle weakness

 defect in the transmission of nerve impulses to muscles.  It occurs when normal communication between the nerve and muscle is interrupted at the neuromuscular junction  Myasthenia gravis is an autoimmune disease because the immune system—which normally protects the body from foreign organisms—mistakenly attacks itself. Causes

 weakness of the eye muscles and eyelid movement  difficulty in swallowing and slurred speech  drooping of one or both eyelids (ptosis)  blurred or double vision (diplopia)  a change in facial expression  shortness of breath  weakness in the arms, hands, fingers, legs, and neck. Symptoms

 Medications include anticholinesterase agents such as neostigmine which help improve neuromuscular transmission and increase muscle strength.  Immunosuppressive drugs such as prednisone. These medications improve muscle strength by suppressing the production of abnormal antibodies  Thymectomy, the surgical removal of the thymus gland (which often is abnormal in individuals with myasthenia gravis)  plasmapheresis, a procedure in which serum containing the abnormal antibodies is removed from the blood while cells are replaced  high-dose intravenous immune globulin, which temporarily modifies the immune system by infusing antibodies from donated blood Treatment

 Plasmaphoresis  IVIG  Plasmapheresis and IVIG are rapid immunotherapies that work quickly but have a short duration of action. These are usually reserved for certain situations, such as myasthenic crisis Myasthenia gravis crisis

 Plasmapheresis is a process in which the liquid in the blood, or plasma, is separated from the cells.  In sick people, plasma can contain antibodies that attack the immune system.  A machine removes the affected plasma and replaces it with good plasma, or a plasma substitute.  The process is similar to kidney dialysis. Plasmapheresis

 A needle or catheter is placed into a vein  Replacement or returned plasma flows into the body through a second tube that is placed in the arm  Treatments can last between one and three hours.  A patient can need as many as five treatments per week.

Plasma exchange machine