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Basic Stroke for the New Recruit

Authors

• Erin Conahan MSN, RN, ACNS-BC, CNRN, SCRN

• Julie Fussner BSN, RN, CPHQ, SCRN

• The authors have nothing to disclose.

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Objectives

• List causes of small vessel stroke vs large vessel stroke and differences in treatment

• Describe inclusion/exclusion criteria for tPA and endovascular treatment

• List elements of acute stroke work-up to identify risk factors

Stroke Facts

• Each year 795,000 strokes occur in the United States

• Stroke is the 5th leading cause of death in the United

States

• Stroke is the leading cause of adult disability

• Up to 80% of strokes are preventable

• During a stroke ~32,000 brain cells are lost per second…

~2 million brain cells lost per minute.

• The brain ages 3.6 years for each hour untreated…

•Time is Brain

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What is stroke?

Stroke occurs when a blood vessel to the brain is blocked

or ruptured causing brain cells in the blood vessel

territory to die.

What does it look like?

• Ischemic Stroke • Hemorrhagic Stroke

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Cerebral Circulation

• Circle of Willis

• Located at the base of the skull

• Provides collateral circulation

• Anterior Circulation

• Carotid arteries

• Anterior cerebral

• Middle cerebral

• Anterior communicating

• Posterior Circulation

• Vertebral

• Basilar

• Posterior cerebral

• Posterior communicating

http://www.merckmanuals.com/professional/neurologic_disorders/stroke_cva/overview_of_stroke.html

5 Stroke Syndromes

1. Left Hemisphere

2. Right Hemisphere

3. Cerebellar

4. Brainstem

5. Hemorrhage

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Left Hemisphere

Signs:

• Aphasia

• Right side weakness

• Right side sensory loss

• Right visual field cut

• Left gaze

Right Hemisphere

Signs:

• Neglect

• Left side weakness

• Left side sensory loss

• Left visual field cut

• Right gaze

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Cerebellar

Signs:

• Ataxia

• Gait disturbance

• Vertigo

• Nystagmus

• Ipsilateral Findings

Retrieved on 9/25/15 from:

http://biology.clc.uc.edu/fankhauser/Labs/Anatomy_&_Physiology/A&P202/202_lecture_notes/05_Mesencephalon_Diencephalon.Jan12.

pdf

Brainstem

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Brainstem

The 5 D’s

Dizziness

Diplopia

Dysarthria

Dysphagia

Dystaxia

Retrieved 9/25/15 from: http://www.americannursetoday.com/assets/0/434/436/440/5120/5122/5154/5156/904adb93-6d32-

4770-83d7-e6f1ad1667d2.pdf

Intracranial Hemorrhages

4 Types

Epidural (trauma)

Subdural (trauma)

Subarachnoid (traumatic or stroke)

Intracerebral hemorrhages (stroke)

Note difference between intraCRANIAL and intraCEREBRAL – both abbreviated “ICH”

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Hemorrhage

Meninges (Outer to Inner)

Retrieved from: http://www.mdguidelines.com/subarachnoid-hemorrhage-non-traumatic. Source: Medical Disability Advisor

• Dura Mater – thick, fibrous covering of brain (and spinal cord)

• Arachnoid Mater – thin web-like membrane between dura and pia, below which flows the CSF in the subarachnoid space

• Pia Mater – delicate covering of the brain and directly adherent to tissue

SAH

Etiology

– Traumatic (fall, blow to head)

– Aneurysmal (ruptured aneurysm)

– AVM (burst of AV malformation)

Signs and symptoms – occur suddenly

– “Worst headache of my life” (thunderclap HA)

– Decrease/loss of consciousness/confusion

– N/V

– Photophobia

– Hemiparesis/hemiplegia

– Meningeal irritation

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Intracerebral Hemorrhage

• Clinical Presentation

• SBP often >220 mmHg

• HA

• N/V

• Ataxia

• Dizziness/Vertigo

• Dysarthria

• Nuchal Rigidity

• Alterations in LOC

Stroke Assessments

• Support airway/breathing/circulation

• Vital signs

• POC Glucose

• CT

• NIHSS

• Labs, EKG, CXR

• CTA or MRA assess vessels

• LP for SAH

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NIH Stroke Scale

• Systematic assessment tool that provides a quantitative measure of stroke used world wide

• 42 point scale

• Higher the number the worse the stroke

• NIHSS 2 or greater tPA given

• “Too good” to treat research

• www.nihss.org

NIH Stroke Scale

• Level of Consciousness Questions & Commands

• Visual Fields

• Facial Palsy

• Motor arm & leg

• Limb ataxia

• Sensory

• Best Language

• Dysarthria

• Neglect

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What type of stroke did your patient have?

• Large vessel occlusion

• Lacunar Infarct

• Transient Ischemic Attack

• Stroke mimics

AIS: Large Artery AtherosclerosisThrombosis

• Plaque narrows the vessel lumen resulting in turbulent blood flow.

• The atherosclerotic plaque becomes unstable and ruptures, clotting factors are attracted and a thrombus forms.

• Carotids / Aorta

• Afib

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AIS: Small Vessel Atherosclerosis

• Small-vessel ischemia occurs when plaque occludes small perforating vessels.

• Typically results in lacunar strokes which accounts for ~ 25% of ischemic strokes.

• Chronic medical conditions such as DM, HTN, HLD and smoking increases risk of small vessel disease.

TIA

• “Mini stroke” - Avoid term

• Brief episode of neurological dysfunction lasting < 1 hour

• Symptoms usually last 10-20 mins

• Old Definition: less than 24 hours

• New Definition: Evidence on MRI imaging

• Important determinant of stroke risk

• 3-10% pts stroke within 2 days

• 9-17% pts stroke within 90 days

• Within 1 year of TIA =12% will die

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Stroke Mimics

• Hypoglycemia

• Seizures

• Migraine

• Tumor

• Abscess

• Subdural Hematoma

Imaging: CT vs MRI

• Why do they order the scan?

• CT better for seeing acute blood or skull fractures

• MRI better for ischemic stroke and tumor

• CTA/MRA looking for blood vessel abnormalities (“A” means angio)

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Treatment options: Time is brain• Blood pressure control for all types!!

• IV tPA

• Endovascular• Pharmacologic• Mechanical

• Neurosurgery• Aneurysmal SAH Clipping and Coiling• External Ventricular Device • Decompressive Hemi craniotomy

• Research

• Neuroscience ICU / Stroke unit

**Find the cause to prevent future events!

tPA Inclusion/Exclusion Criteria

• Contraindications

• ICH, SAH, active internal bleeding

• Recent intracranial or intraspinal surgery or head trauma

• Presence of intracranial conditions that may increase risk of bleeding

• Bleeding diathesis

• Uncontrolled hypertension

• INR > 1.7 or use of NOAC

• 3-4.5 hour window

• >80 years old

• Any anticoagulant use

• History of CVA and diabetes

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Modifiable Risk Factors

• Cardiovascular disease (CVD)

• Hypertension (HTN)

• Asymptomatic carotid stenosis

• A Fib

• Diabetes mellitus (DM)

• Dyslipidemia

• Cigarette smoking

• Drug use ( cocaine)

• Alcohol

• Obesity

• Physical inactivity

• Sickle cell disease

• Postmenopausal hormone therapy

• Hypercoagulable states

Stroke Work-Up

• Cardiac monitoring

• Angiography (CTA, MRA, angio)

• Carotid duplex

• Echocardiogram/TEE

• FLP, HgA1C, Hypercoag panels

• Patient History!!

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Importance of Nursing Assessment

• Ongoing neuro exam: 30% of stroke patients deteriorate in 1st 24 hours

• Bleeding, edema, stroke in evolution; seizures; side effects of treatment

• VS trending

• BP goals, temperature management, cardiac monitoring, oxygenation, blood glucose monitoring

Nursing Role of Preventing Complications

• VTE, Pneumonia

• Nutritional deficiency

• Aspiration

• Bowel or bladder dysfunction, UTI

• Contractures/joint abnormalities

• Skin breakdown

• Depression

• Falls