1. Cerebrovascular Accident (CVA)

2. Definition Ischemia is inadequate blood flow
Brain attack (Stroke) occurs when there is ischemia to a part of the brain that results in death of brain cells

3. Incidence 3rd Cause of death in US and Canada 2/3 in people >65
Statistics
2/3 in people >65
= in men and women
Higher incidence and death rates among African-Americans, Hispanics, Native-American, Asian Americans

4. Risk Factors
Non Modifiable
Age
Gender
Race
Heredity

5. Risk Factors Modifiable Obesity HTN Smoking Heavy alcohol consumption
Hypercoagulability
Hyperlipidemia
Asymptomatic carotid stenosis
Diabetes mellitus
Heart disease, atrial fibrillation
Oral contraceptives
Physical inactivity
Sickle cell disease

6. Review of Cerebral Circulation

7. Blood supply by arteries
Blood is supplied to the brain by two major pairs of arteries
Internal carotid arteries
Vertebral arteries

8. Blood supply by arteries
Carotid arteries branch to supply most of the
Frontal, parietal, and temporal lobes
Basal ganglia
Part of the diencephalon
Thalamus
Hypothalamus

9. Blood supply by arteries
Vertebral arteries join to form the basilar artery, which supply the
Middle and lower temporal lobes
Occipital lobes
Cerebellum
Brainstem
Part of the diencephalon

10. Blood flow to the brain is totally interrupted
“Brain Attack” means:
Blood flow to the brain is totally interrupted

11. Etiology
Atherosclerosis – Disease of the arteries; hardening and thickening of the arterial wall because of soft deposits of intraarterial fat and fibrin that harden over time.

12. Common sites for the development of Atherosclerosis

13. Transient Ischemic Attack (TIA)
Transient ischemic attack (TIA) is a temporary focal loss of neurologic function caused by ischemia
Most TIAs resolve within 3 hours
TIAs are a warning sign of progressive cerebrovascular disease

14. Types of Stroke
Strokes are classified based on the underlying pathophysiologic findings
Ischemic
Hemorrhagic

15. Ischemic vs. Hemorrhagic

16. Ischemic Stroke
Ischemic strokes result from inadequate blood flow to the brain from partial or complete occlusion of an artery
85% of all strokes are ischemic strokes

17. Ischemic Stroke Thrombotic or Embolic
Most patients with ischemic stroke do not have a decreased level of consciousness in the first 24 hours
May progress in the first 72 hours

18. Thrombotic stroke
Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot
Result of thrombosis or narrowing of the blood vessel
Most common cause of stroke

19. Embolic stroke
Occur when an embolus lodges in and occludes a cerebral artery
Results in infarction and edema of the area supplied by the involved vessel
Second most common cause of stroke

20. Embolic stroke
Majority of emboli originate in the inside layer of the heart, with plaque breaking off from the endocardium and entering the circulation
Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms

21. Hemorrhagic Stroke Account for approximately 15% of all strokes
Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles

22. Hemorrhagic Stroke Intracerebral hemorrhage
Bleeding within the brain caused by a rupture of a vessel
Hypertension is the most important cause
Hemorrhage commonly occurs during periods of activity

23. Hemorrhagic Stroke Intracerebral hemorrhage
Manifestations include neurologic deficits, headache, nausea, vomiting, decreased levels of consciousness, and hypertension

24. Hemorrhagic Stroke Subarachnoid hemorrhage
Occurs when there is intracranial bleeding into cerebrospinal fluid-filled space between the arachnoid and pia mater
Commonly caused by rupture of a cerebral aneurysm

25. Clinical Manifestations
Affects many body functions
Motor activity
Elimination
Intellectual function
Spatial-perceptual alterations
Personality
Affect
Sensation
Communication

26. Clinical Manifestations
Brain attack
Term increasingly being used to describe stroke and communicate urgency of recognizing stroke symptoms and treating their onset as a medical emergency

27. Clinical Manifestations Motor Function
Most obvious effect of stroke
Include impairment of
Mobility
Respiratory function
Swallowing and speech
Gag reflex
Self-care abilities

28. Clinical Manifestations Motor Function
An initial period of flaccidity may last from days to several weeks and is related to nerve damage
Spasticity of the muscles follows the flaccid stage and is related to interruption of upper motor neuron influence

29. Clinical Manifestations Communication
Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain
Aphasia is a total loss of comprehension and use of language

30. Diagnostic Studies
When symptoms of a stroke occur, diagnostic studies are done to
Confirm that it is a stroke
Identify the likely cause of the stroke
CT is the primary diagnostic test used after a stroke

31. Diagnostic Studies Additional studies Complete blood count
Platelets, prothrombin time, activated partial thromboplastin time
Electrolytes, blood glucose
Renal and hepatic studies
Lipid profile

32. Collaborative Care Prevention
Goals of stroke prevention include
Health management for the well individual
Education and management of modifiable risk factors to prevent a stroke

33. Collaborative Care Prevention
Antiplatelet drugs are usually the chosen treatment to prevent further stroke in patients who have had a TIA
Aspirin is the most frequently used antiplatelet drug

34. Collaborative Care Prevention
Surgical interventions for the patient with TIAs from carotid disease include
Carotid endarterectomy
Transluminal angioplasty
Stenting
Extracranial-intracranial bypass

35. Collaborative Care Acute Care
Interventions – Initial
Ensure patient airway
Remove dentures
Perform pulse oximetry
Maintain adequate oxygenation
IV access with normal saline
Maintain BP according to guidelines

36. Collaborative Care Acute Care
Interventions – Initial
Remove clothing
Obtain CT scan immediately
Perform baseline laboratory tests
Position head midline
Elevate head of bed 30 degrees if no symptoms of shock or injury

37. Collaborative Care Acute Care
Interventions – Ongoing
Monitor vital signs and neurologic status
Level of consciousness
Motor and sensory function
Pupil size and reactivity
O2 saturation
Cardiac rhythm

38. Collaborative Care Acute Care
Recombinant tissue plasminogen activator (tPA) is used to
Reestablish blood flow through a blocked artery to prevent cell death in patients with acute onset of ischemic stroke symptoms

39. Collaborative Care Acute Care
Thrombolytic therapy given within 3 hours of the onset of symptoms
↓ disability
But at the expense of ↑ in deaths within the first 7 to 10 days and ↑ in intracranial hemorrhage

40. Collaborative Care Acute Care
Surgical interventions for stroke include immediate evacuation of
Aneurysm-induced hematomas
Cerebellar hematomas (>3 cm)

41. Collaborative Care Rehabilitation Care
After the stroke has stabilized for hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning
Patient may be transferred to a rehabilitation unit