Cerebrovascular Accidents CME 2007

Types of CVA’s

IschemicSubarachnoid hemorrhageIntracerebral Hemorrhage

Ischemic CVA

Thrombotic – clot forms in diseased or damaged artery

Embolic- clot travels from distant location, often the heart with atrial fibrillation

Brain Ischemia

Blood flow to a portion of brain is interrupted and can result in tissue death.

Area of damage often localized with specific pattern of symptoms.

Cerebral edema can result from iscemia and increase ICP.

Intracerebral Hemorrhage

Diseased blood vessel bursts and bleeding occurs into brain tissue

Increasing pressure causes damage to surrounding tissue

Subarachnoid Hemorrhage

“Berry” aneurysm bursts, bleeding occurs between brain surface and cranium

Rapid build up of pressure can cause unconsciousness or death

Risk Factors

Atrial fibrillation Anticoagulants

HypertensionHigh cholesterolDiabetesAlcohol abuseSmokingRaceFamily history

Signs & Symptoms

It can be difficult to clinically determine the type of stroke.

Signs and symptoms can include

Confusion

Loss of consciousness

Aphasia

Dizziness or loss of balance

Signs are related to part of brain that is affected and can vary with each patient

Signs can be unilateral

Weakness or paralysis

Numbness Unequal pupils Facial droop

Eyes often provide clues

Unequal pupils

Impaired vision

Extraocular movements

Pinpoint pupils

Signs that may indicate a bleed

Headache

Nausea/vomiting

Progressive onset

Hypertension

Pt takes anticoagulants

History of recent stroke

Signs that favor a clot

Sudden onsetComplaints localized to one limbHistory of Atrial FibrillationHistory of TIA

It is important to recognize the signs of a stroke

And to note the time of their onset.

It is important to know the time of onset of stroke symptoms because

If treatment for embolic strokes using a thrombolytic (clot breaking) medication is appropriate it must be started within three hours.

The sooner these are given, the better.Patients should be transported to a Stroke

Center immediately.

Other diagnostic tools

MRI – can provide more detailed image Cerebral angiography-used to image the

blood vessels of the brain

Don’t forget the “basics”

AirwayBreathingCirculation (blood pressure and pulse)

Blood glucose (hypoglycemia can often appear like a stroke)

Drugs and alcohol can too.

CPP=MAP - ICPIf the intercranial pressure is high

a high blood pressure is necessary to perfuse the brain.

History and physical key points

carotid bruits Sensation and motor

function in each extremity (grasp, flexor, extensor)

Pupils and ocular movement

Gait (if possible) Mental status

EKG SpO2 ABG’s ICP monitor Glucose I/O Labs: INR, CBC, Plt

Treatment considerations

Dilantin Vitamin K / FFP Blood pressure

control

Heparin Aspirin?

Diagnostics

The cause of a CVA is usually determined by head CT

Note the positive “arrow” sign

Hypoperfused region is dark

Thrombolytics

Treatment for embolic strokestPA tissue plasminogen activator dissolves

fibrin clotsHas potential to prevent permanent brain

iscemiaCan cause catastrophic hemorrhage in

some patients

Thrombolytic check list

  INCLUSION criteria (must all be

YES) Age 18 years or older ___ Time of onset well established to be

less than 3 hours ___ Clinical diagnosis of ischemic stroke

causing a ___ measurable neurological deficit CT without hemorrhage ___ Risks/benefits: Discussed and

documented in chart ___   EXCLUSION criteria (must all be

NO) SBP>185 or DBP>110 despite simple

measures ___ Symptoms rapidly improving or minor

symptoms (NIHSS = 0) ___

Coma or severe obtundation ___ Seizure at onset ___ Symptoms of subarachnoid hemorrhage

___ Stroke or head trauma within 3 months

___ Major surgery within 14 days ___ History of intracranial hemorrhage ___ GI hemorrhage or urinary tract

hemorrhage within 21 days ___ Arterial puncture at a noncompressible

site or LP within 7 days ___ Recent MI complicated by pericarditis

___ Patients receiving heparin within 48hrs

and with an elevated PTT ___ PT greater than 15 (»INR > 1.7) ___ Platelet count < 100,000 ___ Glucose below 50 or above 400 ___ Pregnant (Note: menstruation is NOT a

contraindication) ___

Treatment for hemorrhagic strokes

Surgically clipping a berry aneurysm

Coil placed in aneurysm

Stent placed in

Vertebral artery.