Brain anatomy & physiologyBrain anatomy & physiologyand Neurological Assessmentand Neurological Assessment

James Bitmead James Bitmead (Clinical Practice Facilitator, UCLH)(Clinical Practice Facilitator, UCLH)

Angela RootsAngela Roots(Practice Development Nurse, GSTT)(Practice Development Nurse, GSTT)

What is a stroke?What is a stroke?

interruption of the blood supply to the interruption of the blood supply to the brain, caused by a blocked or burst blood brain, caused by a blocked or burst blood vessel…cuts off the supply of oxygen and vessel…cuts off the supply of oxygen and nutrients, causing damage to the brain nutrients, causing damage to the brain tissue. (World Health Organisation 2010) tissue. (World Health Organisation 2010)

Aetiology of StrokeAetiology of Stroke

Cerebral infarction/ischaemicCerebral infarction/ischaemic 81% 81% Intracerebral haemorrhageIntracerebral haemorrhage 13%13%Subarachnoid haemorrhageSubarachnoid haemorrhage 6%6%Risk of recurrence within 5 years Risk of recurrence within 5 years 30-30-

40% (Stroke Association 2010)40% (Stroke Association 2010)

1. Frontal LobeControls:• Behaviour • Emotions• Organisation• Personality• Planning• Problem solvingArteries: ACA, MCA

6. Hippocampus Controls:• Object recognition• Stores meaning of

words or places

Arteries: PCA

3. Occipital LobeControls:• Colour

recognition• Shape

recognitionArteries: PCA

2. Parietal LobeControls:• Judgement of

shape,size,texture,and weight

• The sensation ofpressure and touch

• Understanding ofspoken/writtenlanguage Arteries: ACA, MCA

7. Temporal lobeControls:• Smell

Identification• Sound

Identification• Short-term

Memory• Hearing Arteries: MCA, PCA

4. CerebellumControls:• Balance• Muscle

co-ordination• Posture

maintenanceArteries: BasilarPICA, AICA, SCA

5. BrainstemControls:• Alertness• Blood pressure• Digestion• Breathing• Heart rate

Arteries: Vertebral Basilar

12

34 7

4

5

4

6

ACA = Anterior Cerebral Artery MCA = Middle Cerebral Artery

PCA = Posterior Cerebral ArteryPICA = Posterior Inferior Cerebellar ArteryAICA = Anterior Inferior Cerebellar Artery

SCA = Superior Cerebellar Artery

Speech centresSpeech centres

Broca; Broca; control the control the muscles of the larynx, muscles of the larynx, pharynx and mouth pharynx and mouth that enable us to that enable us to speakspeak

Wernicke’s areaWernicke’s area, , injury here may result injury here may result in receptive in receptive dysphasia.dysphasia.

Contra-lateral ControlContra-lateral Control

Blood Supply to the BrainBlood Supply to the Brain

Lacunar StrokeLacunar Stroke

Ischemic stroke Ischemic stroke (Thrombo/embolic stroke(Thrombo/embolic stroke))

hypercholesterolemia hypercholesterolemia hypertensionhypertension Atrial fibrillationAtrial fibrillation Ischaemic heart Ischaemic heart

disease/angina disease/angina Peripheral vascular Peripheral vascular

diseasedisease DiabetesDiabetes

Previous stroke/TIAPrevious stroke/TIA SmokingSmoking Increased alcohol Increased alcohol

intakeintake Poor diet/obesityPoor diet/obesity Increased age-Increased age-

atherosclerosisatherosclerosis Oral Contraceptive Oral Contraceptive

PillPill Drug misuseDrug misuse

Haemorrhagic StrokeHaemorrhagic Stroke

Chronic high blood Chronic high blood pressure.pressure.

Amphetamine. Amphetamine. Amyloid angiopathyAmyloid angiopathy Arterial Venous Arterial Venous

malformation (AVM), malformation (AVM), inflammation of blood inflammation of blood

vessels (vasculitis), vessels (vasculitis), bleeding disorders, bleeding disorders, anticoagulants, anticoagulants,

Intracerebral and subarachnoid Intracerebral and subarachnoid haemorrhagehaemorrhage

Subdural haemorrhage and small Subdural haemorrhage and small vessel diseasevessel disease

Raised Intracranial PressureRaised Intracranial Pressure

Early SignsEarly Signs AgitationAgitation VomitingVomiting HeadacheHeadache Dilated pupilsDilated pupils

Later SignsLater Signs Increased systolic Increased systolic

blood pressureblood pressure BradicardiaBradicardia Abnormal respiratory Abnormal respiratory

patternpattern

Causes and TreatmentCauses and Treatment

CausesCauses OedemaOedema HaemorrhageHaemorrhage TumourTumour EncephalopathyEncephalopathy

TreatmentTreatment SteroidsSteroids ManitolManitol HyperventilationHyperventilation HemicraniectomyHemicraniectomy

HemicraniectomyHemicraniectomy

Neurological AssessmentNeurological Assessment

AVPU – what does this mean?AVPU – what does this mean?Blood sugarBlood sugarPupilsPupilsThen move onto GCS and full neuro Then move onto GCS and full neuro

assessmentassessment

Illustration of GCSIllustration of GCS

The Glasgow Coma ScaleThe Glasgow Coma Scale

The eye opening category is performed The eye opening category is performed once the patient is fully awake not beforeonce the patient is fully awake not before

The verbal category means a verbal The verbal category means a verbal response – the patient has to verbally response – the patient has to verbally indicate their orientation to time, place and indicate their orientation to time, place and person to be orientatedperson to be orientated

Mute dysphasic patients cannot score 5 on Mute dysphasic patients cannot score 5 on the verbal categorythe verbal category

The Glasgow Coma ScaleThe Glasgow Coma Scale

The motor response is best done without The motor response is best done without the patient copying your action – truly the patient copying your action – truly obeying command not copying!obeying command not copying!

Score the GCS in your documentation as Score the GCS in your documentation as GCS=15 E 4 V 5 M6GCS=15 E 4 V 5 M6

MRC limb power gradingMRC limb power grading

5= full strength5= full strength4=able to move against resistance but 4=able to move against resistance but

easily overcomeeasily overcome3= able to move against gravity but not 3= able to move against gravity but not

resistanceresistance2= able to move but not against gravity2= able to move but not against gravity1= flicker1= flicker0= no movement0= no movement

Neurological assessmentNeurological assessmentScore the patient as you see them – no Score the patient as you see them – no

guessing or backdating the resultsguessing or backdating the results If they do not meet one criteria move down If they do not meet one criteria move down

the score to the next onethe score to the next oneAlways start the assessment with the Always start the assessment with the

patient as awake as possible (even at patient as awake as possible (even at 2am)2am)

Changing GCSChanging GCS If patient looks different to the GCS If patient looks different to the GCS

scoring do a set of obs together at hand scoring do a set of obs together at hand overover

Consistency with using the neuro. Obs is Consistency with using the neuro. Obs is vital to detecting changes in the patientsvital to detecting changes in the patients

Don’t forget to spot other changes like Don’t forget to spot other changes like increasing confusion even if the GCS increasing confusion even if the GCS hasn’t yet changedhasn’t yet changed

Patterns of change in GCSPatterns of change in GCS

Dropping obviously!Dropping obviously!Fluctuating widely – could it represent Fluctuating widely – could it represent

seizure (sub-clinically)seizure (sub-clinically) Increasing difficulty in obtaining the same Increasing difficulty in obtaining the same

GCSGCSSmall changes within the category – e.g. Small changes within the category – e.g.

confused but worsening confusion, obeys confused but worsening confusion, obeys some commands but not otherssome commands but not others

Vital signs changes- will come to laterVital signs changes- will come to later

ESCALATE!!!!ESCALATE!!!!

If you are concerned at all, do not be afraid If you are concerned at all, do not be afraid to escalate!!!!!to escalate!!!!!

Band 6Band 6Site Nurse PractitionerSite Nurse PractitionerConsultant oncallConsultant oncall