Cerebrovascular Accident CVA. Cerebrovascular Accident Results from ischemia to a part of the brain or hemorrhage into the brain that results in death

Cerebrovascular AccidentCerebrovascular Accident

CVACVA

Cerebrovascular AccidentCerebrovascular Accident Results from ischemia to a part of the brain or Results from ischemia to a part of the brain or

hemorrhage into the brain that results in death of brain hemorrhage into the brain that results in death of brain cellscells. .

Approximately 750,000 in USA annuallyApproximately 750,000 in USA annually Third most common cause of death Third most common cause of death #1 leading cause of disability #1 leading cause of disability 25% with initial stroke die within 1 year25% with initial stroke die within 1 year 50-75% will be functionally independent50-75% will be functionally independent 25% will live with permanent disability25% will live with permanent disability

Physical, cognitive, emotional, & financial impactPhysical, cognitive, emotional, & financial impact

Cerebrovascular AccidentCerebrovascular AccidentRisk FactorsRisk Factors

Nonmodifiable:Nonmodifiable:

Age Age – Occurrence doubles each decade >55 years– Occurrence doubles each decade >55 years

GenderGender – Equal for men & women; women die more frequently – Equal for men & women; women die more frequently than menthan men

Race Race – African Americans, Hispanics, Native Americans, Asian – African Americans, Hispanics, Native Americans, Asian Americans -- higher incidence Americans -- higher incidence

Heredity Heredity – family history, prior transient ischemic attack, or prior – family history, prior transient ischemic attack, or prior stroke increases riskstroke increases risk

Cerebrovascular AccidentCerebrovascular AccidentRisk FactorsRisk Factors

Controllable Risks with Medical Treatment & Controllable Risks with Medical Treatment & Lifestyle Changes:Lifestyle Changes:

High blood pressure DiabetesCigarette smoking TIA (Aspirin)High blood cholesterol ObesityHeart Disease Atrial fibrillation

Oral contraceptive use Physical inactivity

Sickle cell disease Asymptomatic carotid stenosisAsymptomatic carotid stenosisHypercoagulabilityHypercoagulability

CVA – Risk FactorsCVA – Risk Factors

Cerebrovascular AccidentCerebrovascular AccidentAnatomy of Cerebral CirculationAnatomy of Cerebral Circulation

Blood SupplyBlood Supply

Anterior: Carotid ArteriesAnterior: Carotid Arteries – middle & anterior – middle & anterior cerebral arteriescerebral arteries

frontal, parietal, temporal lobes; basal ganglion; part of the frontal, parietal, temporal lobes; basal ganglion; part of the diencephalon (thalamus & hypothalamus)diencephalon (thalamus & hypothalamus)

Posterior: Vertebral ArteriesPosterior: Vertebral Arteries – basilar artery – basilar artery Mid and lower temporary & occipital lobes, cerebellum, Mid and lower temporary & occipital lobes, cerebellum,

brainstem, & part of the diencephalonbrainstem, & part of the diencephalon

Circle of WillisCircle of Willis – connects the anterior & posterior cerebral – connects the anterior & posterior cerebral circulationcirculation

Cerebrovascular AccidentCerebrovascular AccidentAnatomy of Cerebral CirculationAnatomy of Cerebral Circulation

Blood SupplyBlood Supply

20% of cardiac output—750-1000ml/min20% of cardiac output—750-1000ml/min

>30 second interruption– neurologic >30 second interruption– neurologic metabolism is altered; metabolism stops in 2 metabolism is altered; metabolism stops in 2 minutes; brain cell death < 5 mins.minutes; brain cell death < 5 mins.

Cerebrovascular AccidentCerebrovascular AccidentPathophysiologyPathophysiology

AtherosclerosisAtherosclerosis: major cause of CVA: major cause of CVA Thrombus formation & emboli developmentThrombus formation & emboli development

Abnormal filtration of lipids in the intimal layer of the arterial Abnormal filtration of lipids in the intimal layer of the arterial wallwall

Plaque develops & locations of increased turbulence of blood - Plaque develops & locations of increased turbulence of blood - bifurcationsbifurcations

Increased turbulence of blood or a tortuous areaIncreased turbulence of blood or a tortuous area Calcified plaques rupture or fissureCalcified plaques rupture or fissure Platelets & fibrin adhere to the plaquePlatelets & fibrin adhere to the plaque Narrowing or blockage of an artery by thrombus or emboliNarrowing or blockage of an artery by thrombus or emboli Cerebral Infarction: blocked artery with blood supply cut Cerebral Infarction: blocked artery with blood supply cut

off beyond the blockageoff beyond the blockage

Cerebrovascular AccidentCerebrovascular AccidentPathophysiologyPathophysiology

Ischemic CascadeIschemic Cascade Series of metabolic eventsSeries of metabolic events

Inadequate ATP adenosine triphosphate productionInadequate ATP adenosine triphosphate production Loss of ion homeostasisLoss of ion homeostasis Release of excitatory amino acids – glutamateRelease of excitatory amino acids – glutamate Free radical formationFree radical formation Cell deathCell death

Border ZoneBorder Zone: reversible area that surrounds the core : reversible area that surrounds the core ischemic area in which there is reduced blood flow but ischemic area in which there is reduced blood flow but which can be restored which can be restored (3 hours +/-)(3 hours +/-)

CVA? - Call 911CVA? - Call 911

Sudden numbness or weakness of face, arm, or leg, especially on Sudden numbness or weakness of face, arm, or leg, especially on one side of the body. one side of the body.

Sudden confusion or trouble speaking or understanding speech. Sudden confusion or trouble speaking or understanding speech.

Sudden trouble seeing in one or both eyes. Sudden trouble seeing in one or both eyes.

Sudden trouble walking, dizziness, or loss of balance or Sudden trouble walking, dizziness, or loss of balance or coordination coordination

Sudden severe headache with no known cause. Sudden severe headache with no known cause.

Cerebrovascular AccidentCerebrovascular AccidentTransient Ischemic AttackTransient Ischemic Attack

Temporary focal loss of neurologic function Temporary focal loss of neurologic function

Caused by ischemia of one of the vascular territories of Caused by ischemia of one of the vascular territories of the brainthe brain Microemboli with temporary blockage of blood flowMicroemboli with temporary blockage of blood flow

Lasts less than 24 hrs – often less than 15 minsLasts less than 24 hrs – often less than 15 mins

Most resolve within 3 hoursMost resolve within 3 hours

Warning sign of progressive cerebrovascular diseaseWarning sign of progressive cerebrovascular disease

Cerebrovascular AccidentCerebrovascular Accident Transient Ischemic AttackTransient Ischemic Attack

Diagnosis: Diagnosis: CT without contrast CT without contrast

Confirm that TIA is not related to brain lesions Confirm that TIA is not related to brain lesions Cardiac EvaluationCardiac Evaluation

Rule out cardiac mural thrombiRule out cardiac mural thrombi

Treatment:Treatment: Medications that prevent platelet aggregationMedications that prevent platelet aggregation

ASA, PlavixASA, Plavix Oral anticoagulantsOral anticoagulants

Cerebrovascular AccidentCerebrovascular AccidentClassifications Classifications

Based on underlying pathophysiologic findingsBased on underlying pathophysiologic findings

Cerebrovascular AccidentCerebrovascular AccidentClassificationsClassifications

Ischemic StrokeIschemic Stroke ThromboticThrombotic EmbolicEmbolic

Hemorrhagic StrokeHemorrhagic Stroke Intracerebral HemorrhageIntracerebral Hemorrhage Subarachnoid HemorrhageSubarachnoid Hemorrhage

AneurysmAneurysm Berry or SaccularBerry or Saccular

Cerebrovascular AccidentCerebrovascular AccidentClassificationsClassifications

Ischemic StrokeIschemic Stroke—inadequate blood flow to the brain from partial —inadequate blood flow to the brain from partial or complete occlusions of an artery--85% of all strokesor complete occlusions of an artery--85% of all strokes

Extent of a stroke depends on:Extent of a stroke depends on: Rapidity of onsetRapidity of onset Size of the lesionSize of the lesion Presence of collateral circulationPresence of collateral circulation

Symptoms may progress in the first 72 hours as infarction & Symptoms may progress in the first 72 hours as infarction & cerebral edema increasecerebral edema increase

Types of Ischemic StrokeTypes of Ischemic Stroke: :

Thrombotic StrokeThrombotic Stroke Embolic StrokeEmbolic Stroke

CVA RecognitionCVA Recognition

Cerebrovascular AccidentCerebrovascular AccidentIschemic – Thrombotic StrokeIschemic – Thrombotic Stroke

Lumen of the blood vessels narrow – then Lumen of the blood vessels narrow – then becomes occluded – infarctionbecomes occluded – infarction

Associated with HTN and Diabetes MellitusAssociated with HTN and Diabetes Mellitus >60% of strokes>60% of strokes 50% are preceded by TIA50% are preceded by TIA Lacunar Stroke: development of cavity in place of Lacunar Stroke: development of cavity in place of

infarcted brain tissue – results in considerable infarcted brain tissue – results in considerable deficits – motor hemiplegia, contralateral loss of deficits – motor hemiplegia, contralateral loss of sensation or motor abilitysensation or motor ability

Cerebrovascular AccidentCerebrovascular AccidentThrombotic StrokeThrombotic Stroke

Cerebrovascular AccidentCerebrovascular AccidentCommon Sites of AtherosclerosisCommon Sites of Atherosclerosis

Cerebrovascular AccidentCerebrovascular AccidentIschemic – Embolic StrokeIschemic – Embolic Stroke

Embolus lodges in and occludes a cerebral arteryEmbolus lodges in and occludes a cerebral artery Results in infarction & cerebral edema of the area Results in infarction & cerebral edema of the area

supplied by the vesselsupplied by the vessel Second most common cause of stroke – 24%Second most common cause of stroke – 24% Emboli originate in endocardial layer of the heart – atrial Emboli originate in endocardial layer of the heart – atrial

fibrillation, MI, infective endocarditis, rheumatic heart fibrillation, MI, infective endocarditis, rheumatic heart disease, valvular prosthesesdisease, valvular prostheses

Rapid occurrence with severe symptoms – body does not Rapid occurrence with severe symptoms – body does not have time to develop collateral circulationhave time to develop collateral circulation

Any age groupAny age group Recurrence common if underlying cause not treated Recurrence common if underlying cause not treated

Cerebrovascular AccidentCerebrovascular AccidentEmbolic StrokeEmbolic Stroke

Cerebrovascular AccidentCerebrovascular AccidentGoals for ManagementGoals for Management

Immediate – assess & stabilizeImmediate – assess & stabilize ABCs, VSABCs, VS Neurologic screeningNeurologic screening Oxygen if hypoxicOxygen if hypoxic IV access IV access Check glucoseCheck glucose Activate stroke team – Activate stroke team – CODE GREENCODE GREEN 12-lead EKG12-lead EKG

Immediate Neuro AssessmentImmediate Neuro Assessment Establish symptom onsetEstablish symptom onset

Review hxReview hx Stroke Scale Stroke Scale Facial droop; arm drift; abnormal speechFacial droop; arm drift; abnormal speech


CT Scan – No hemorrhage:CT Scan – No hemorrhage: Consider Fibrinolytic therapyConsider Fibrinolytic therapy

Check for exclusionsCheck for exclusions tPAtPA

No anticoagulants or antiplatelet therapy for 24 hoursNo anticoagulants or antiplatelet therapy for 24 hours If not a candidate: Antiplatelet TherapyIf not a candidate: Antiplatelet Therapy

CT Scan – Hemorrhage:CT Scan – Hemorrhage: Neurosurgery?Neurosurgery? If no surgery: Stroke UnitIf no surgery: Stroke Unit

Monitor BP and treat HypertensionMonitor BP and treat Hypertension Monitor Neuro statusMonitor Neuro status Monitor blood glucose and treat as neededMonitor blood glucose and treat as needed Supportive therapySupportive therapy


Immediate – assess & stabilizeImmediate – assess & stabilize ABCs, VSABCs, VS Neurologic screeningNeurologic screening Oxygen if hypoxicOxygen if hypoxic IV access IV access Check glucoseCheck glucose Active stroke teamActive stroke team Emergent CT scan of brainEmergent CT scan of brain 12-lead EKG12-lead EKG

Immediate Neuro AssessmentImmediate Neuro Assessment Establish symptom onsetEstablish symptom onset

Review hxReview hx Stroke Scale Stroke Scale Facial droop; arm drift; abnormal speechFacial droop; arm drift; abnormal speech

Cerebrovascular AccidentCerebrovascular AccidentHemorrhagic StrokeHemorrhagic Stroke

Hemorrhagic StrokeHemorrhagic Stroke 15% of all strokes15% of all strokes Result from bleeding into the brain tissue Result from bleeding into the brain tissue

itself itself IntracerebralIntracerebralSubarachnoidSubarachnoid

Cerebrovascular AccidentCerebrovascular AccidentHemorrhage Stroke Hemorrhage Stroke

Intracerebral HemorrhageIntracerebral Hemorrhage

Rupture of a vesselRupture of a vessel Hypertension – most important causeHypertension – most important cause Others: vascular malformations, coagulation Others: vascular malformations, coagulation

disorders, anticoagulation, trauma, brain tumor, disorders, anticoagulation, trauma, brain tumor, ruptured aneurysmsruptured aneurysms

Sudden onset of symptoms with progressionSudden onset of symptoms with progression Neurological deficits, headache, nausea, vomiting, Neurological deficits, headache, nausea, vomiting,

decreased LOC, and hypertensiondecreased LOC, and hypertension Prognosis: poor – 50% die within weeksPrognosis: poor – 50% die within weeks 20% functionally independent at 6 months20% functionally independent at 6 months

Cerebrovascular AccidentCerebrovascular AccidentHemorrhage Stroke Hemorrhage Stroke

Intracerebral HemorrhageIntracerebral Hemorrhage

Cerebrovascular AccidentCerebrovascular AccidentHemorrhagic-SubarachnoidHemorrhagic-Subarachnoid

Hemorrhagic Stroke–Subarachnoid HemorrhageHemorrhagic Stroke–Subarachnoid Hemorrhage

Intracranial bleeding into the cerebrospinal fluid-Intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater filled space between the arachnoid and pia mater membranes on the surface of the brain membranes on the surface of the brain

Cerebrovascular AccidentCerebrovascular Accident Hemorrhagic-SubarachnoidHemorrhagic-Subarachnoid

Commonly caused by rupture of cerebral aneurysmCommonly caused by rupture of cerebral aneurysm (congenital or acquired)(congenital or acquired)

Saccular or berry – few to 20-30 mm in sizeSaccular or berry – few to 20-30 mm in size Majority occur in the Circle of WillisMajority occur in the Circle of Willis

Other causes: Arteriovenous malformation (AVM), Other causes: Arteriovenous malformation (AVM), trauma, illicit drug abusetrauma, illicit drug abuse

Incidence: 6-16/100,000Incidence: 6-16/100,000 Increases with age and more common in womenIncreases with age and more common in women

Cerebrovascular AccidentCerebrovascular Accident Hemorrhagic-SubarachnoidHemorrhagic-Subarachnoid

Cerebral AneurysmCerebral Aneurysm Warning Symptoms: sudden onset of a severe Warning Symptoms: sudden onset of a severe

headache – “worst headache of one’s life”headache – “worst headache of one’s life”

Change of LOC, Neurological deficits, nausea, Change of LOC, Neurological deficits, nausea, vomiting, seizures, stiff neckvomiting, seizures, stiff neck

Despite improvements in surgical techniques, Despite improvements in surgical techniques, many patients die or left with significant many patients die or left with significant cognitivecognitive difficultiesdifficulties

Hemorrhagic-SubarachnoidHemorrhagic-Subarachnoid Cerebral AneurysmCerebral Aneurysm

Surgical Treatment:Surgical Treatment:

Clipping the aneurysm – prevents rebleedClipping the aneurysm – prevents rebleed Coiling – platinum coil inserted into the lumen of the Coiling – platinum coil inserted into the lumen of the

aneurysm to occlude the sacaneurysm to occlude the sac

Postop: Vasospasm prevention – Calcium Channel Postop: Vasospasm prevention – Calcium Channel BlockersBlockers

Hemorrhagic-SubarachnoidHemorrhagic-Subarachnoid Cerebral Aneurysm – Surgical TxCerebral Aneurysm – Surgical Tx

Hemorrhagic-SubarachnoidHemorrhagic-Subarachnoid Cerebral Aneurysm – CoilingCerebral Aneurysm – Coiling

Cerebrovascular AccidentCerebrovascular AccidentClassificationClassification

Cerebrovascular AccidentCerebrovascular AccidentClinical ManifestationsClinical Manifestations

Middle Cerebral Artery InvolvementMiddle Cerebral Artery Involvement Contralateral weaknessContralateral weakness

Hemiparesis; hemiplegiaHemiparesis; hemiplegia Contralateral hemianesthesiaContralateral hemianesthesia Loss of proprioception, fine touch and localizationLoss of proprioception, fine touch and localization Dominant hemisphere: aphasiaDominant hemisphere: aphasia Nondominant hemisphere – neglect of opposite side; Nondominant hemisphere – neglect of opposite side;

anosognosia – unaware or denial of neuro deficitanosognosia – unaware or denial of neuro deficit Homonymous hemianopsia – defective vision or Homonymous hemianopsia – defective vision or

blindness right or left halves of visual fields of both blindness right or left halves of visual fields of both eyeseyes


Anterior Cerebral Artery InvolvementAnterior Cerebral Artery Involvement Brain stem occlusionBrain stem occlusion Contralateral Contralateral

weakness of proximal upper extremityweakness of proximal upper extremity sensory & motor deficits of lower extremitiessensory & motor deficits of lower extremities

Urinary incontinenceUrinary incontinence Sensory loss (discrimination, proprioception)Sensory loss (discrimination, proprioception) Contralateral grasp & sucking reflexes may be presentContralateral grasp & sucking reflexes may be present Apraxia – loss of ability to carry out familiar purposeful Apraxia – loss of ability to carry out familiar purposeful

movements in the absence of sensory or motor impairmentmovements in the absence of sensory or motor impairment Personality change: flat affect, loss of spontaneity, loss of Personality change: flat affect, loss of spontaneity, loss of

interest in surroundingsinterest in surroundings Cognitive impairmentCognitive impairment


Posterior Cerebral Artery & Posterior Cerebral Artery & Vertebrobasilar InvolvementVertebrobasilar Involvement

Alert to comatoseAlert to comatose Unilateral or bilateral sensory lossUnilateral or bilateral sensory loss Contralateral or bilateral weaknessContralateral or bilateral weakness Dysarthria – impaired speech articulation Dysarthria – impaired speech articulation Dysphagia – difficulty in swallowingDysphagia – difficulty in swallowing HoarsenessHoarseness Ataxia, Vertigo Ataxia, Vertigo Unilateral hearing lossUnilateral hearing loss Visual disturbances (blindness, homonymous Visual disturbances (blindness, homonymous

hemianopsia, nystagmus, diplopia)hemianopsia, nystagmus, diplopia)


Motor Function ImpairmentMotor Function Impairment Caused by destruction of motor neurons in the Caused by destruction of motor neurons in the

pyramidal pathway (brain to spinal cord)pyramidal pathway (brain to spinal cord) MobilityMobility Respiratory functionRespiratory function Swallowing and speechSwallowing and speech Gag reflexGag reflex Self-care activitiesSelf-care activities


Right Brain – Left Brain DamageRight Brain – Left Brain Damage


AffectAffect Difficulty controlling emotionsDifficulty controlling emotions Exaggerated or unpredictable emotional responseExaggerated or unpredictable emotional response Depression / feelings regarding changed body Depression / feelings regarding changed body

image and loss of functionimage and loss of function


Intellectual FunctionIntellectual Function Memory and judgment Memory and judgment

Left-brain stroke: cautious in making judgmentsLeft-brain stroke: cautious in making judgments Right-brain stroke: impulsive & moves quickly to Right-brain stroke: impulsive & moves quickly to

decisionsdecisions Difficulties in learning new skillsDifficulties in learning new skills


CommunicationCommunication Left hemisphere dominant for language skills in the Left hemisphere dominant for language skills in the

right-handed person & most left-handed persons -- right-handed person & most left-handed persons -- Aphasia/DysphasiaAphasia/Dysphasia

Involvement Expression & ComprehensionInvolvement Expression & Comprehension Receptive Aphasia (Wernicke’s area):Receptive Aphasia (Wernicke’s area): sounds of speech sounds of speech

nor its meaning can be understood – spoken & writtennor its meaning can be understood – spoken & written Expressive Aphasia (Broca’s area):Expressive Aphasia (Broca’s area): difficulty in difficulty in

speaking and writingspeaking and writing Dysarthria:Dysarthria: Affects the mechanics of speech due to Affects the mechanics of speech due to

muscle control disturbances – pronunciation, articulation, muscle control disturbances – pronunciation, articulation, and phonationand phonation


Spatial-Perceptual Alterations – 4 categories:Spatial-Perceptual Alterations – 4 categories:

1. Incorrect perception of self & illness1. Incorrect perception of self & illness 2. Erroneous perception of self in space – may neglect 2. Erroneous perception of self in space – may neglect

all input from the affected side (worsened by all input from the affected side (worsened by homonymous hemianopsia)homonymous hemianopsia)

3. Agnosia: Inability to recognize an object by sight, 3. Agnosia: Inability to recognize an object by sight, touch or hearingtouch or hearing

4. Apraxia: Inability to carry out learned sequential 4. Apraxia: Inability to carry out learned sequential movements on command movements on command

Homonymous HemianopsiaHomonymous Hemianopsia


Elimination

Most problems occur initially and are temporaryMost problems occur initially and are temporary One hemisphere stroke: prognosis is excellent for One hemisphere stroke: prognosis is excellent for

normal bladder functionnormal bladder function Bowel elimination: motor control not a problem – Bowel elimination: motor control not a problem –

constipation associated with immobility, weak constipation associated with immobility, weak abdominal muscles, dehydration, diminished abdominal muscles, dehydration, diminished response to the defecation reflexresponse to the defecation reflex

Cerebrovascular AccidentCerebrovascular AccidentTreatment GoalsTreatment Goals

Prevention – Health Maintenance Focus:Prevention – Health Maintenance Focus: Healthy dietHealthy diet Weight controlWeight control Regular exerciseRegular exercise No smokingNo smoking Limit alcohol consumptionLimit alcohol consumption Route health assessmentRoute health assessment Control of risk factorsControl of risk factors


PreventionPrevention Drug TherapyDrug Therapy Surgical TherapySurgical Therapy RehabilitationRehabilitation

Cerebrovascular AccidentCerebrovascular AccidentDiagnostic StudiesDiagnostic Studies

Done to confirm CVA and identify causeDone to confirm CVA and identify cause PE: Neuro Assessment; Carotid bruit PE: Neuro Assessment; Carotid bruit Carotid doppler studies (ultrasound study)Carotid doppler studies (ultrasound study) CT – primary – identifies size, location, differentiates CT – primary – identifies size, location, differentiates

between ischemic and hemorrhagicbetween ischemic and hemorrhagic CTA – CT Angiography – visualizes vasculatureCTA – CT Angiography – visualizes vasculature MRI – greater specificity than CT MRI – greater specificity than CT

May not be able to be used on all patients (metal, May not be able to be used on all patients (metal, claustrophobia)claustrophobia)

Angiography: gold standard for imaging carotid arteriesAngiography: gold standard for imaging carotid arteries


Drug TherapyDrug Therapy – Thrombotic CVA – to reestablish blood – Thrombotic CVA – to reestablish blood flow through a blocked arteryflow through a blocked artery

Thrombolytic DrugsThrombolytic Drugs: tPA (tissue plasminogen activator) : tPA (tissue plasminogen activator) produce localized fibrinolysis by binding to the fibrin in the produce localized fibrinolysis by binding to the fibrin in the

thrombithrombi Plasminogen is converted to plasmin (fibrinolysin)Plasminogen is converted to plasmin (fibrinolysin) Enzymatic action digests fibrin & fibrinogenEnzymatic action digests fibrin & fibrinogen Results is clot lysisResults is clot lysis

Administered within 3 hours of symptoms of ischemic Administered within 3 hours of symptoms of ischemic CVACVA Confirmed DX with CTConfirmed DX with CT Patient anticoagulatedPatient anticoagulated

ASA, Calcium Channel BlockersASA, Calcium Channel Blockers

CVA - Treatment GoalsCVA - Treatment Goals Surgical TreatmentSurgical Treatment

Carotid endarterectomyCarotid endarterectomy – – preventive preventive – > 100,000/year– > 100,000/year removal of atheromatous lesionsremoval of atheromatous lesions

Clipping, wrapping, coiling AneurysmClipping, wrapping, coiling Aneurysm

Evacuation of aneurysm-induced hematomas larger Evacuation of aneurysm-induced hematomas larger than 3 cm.than 3 cm.

Treatment of AV MalformationsTreatment of AV Malformations

Carotid Artery DiseaseCarotid Artery Disease

Carotid Artery DiseaseCarotid Artery Disease Carotid artery disease is the leading cause of strokes. Carotid artery disease is the leading cause of strokes.

More than 5More than 50% of stroke victims present no warning signs.0% of stroke victims present no warning signs. After age 55, the risk of stroke doubles every 10 years. After age 55, the risk of stroke doubles every 10 years.

97% of the adult population cannot name a single 97% of the adult population cannot name a single warning sign of a stroke.warning sign of a stroke.

50% of nursing home admissions are stroke victims50% of nursing home admissions are stroke victims

Carotid Artery StentsCarotid Artery Stents

Carotid EndarterectomyCarotid Endarterectomy


Drug TherapyDrug Therapy Measures to prevent the development of a thrombus or Measures to prevent the development of a thrombus or

embolus for “At Risk” patients:embolus for “At Risk” patients:

Antiplatelet AgentsAntiplatelet Agents AspirinAspirin PlavixPlavix CombinationCombination

Oral anticoagulation – Coumadin Oral anticoagulation – Coumadin Treatment of choice for individuals with atrial fibrillation who have had Treatment of choice for individuals with atrial fibrillation who have had

a TIAa TIA

Cerebrovascular AccidentCerebrovascular AccidentNursing DiagnosesNursing Diagnoses

Ineffective tissue perfusion r/t decreased Ineffective tissue perfusion r/t decreased cerebrovascular blood flowcerebrovascular blood flow

Ineffective airway clearanceIneffective airway clearance Impaired physical mobilityImpaired physical mobility Impaired verbal communicationImpaired verbal communication Impaired swallowingImpaired swallowing Unilateral neglect r/t visual field cut & sensory lossUnilateral neglect r/t visual field cut & sensory loss Impaired urinary eliminationImpaired urinary elimination Situational low self-esteem r/t actual or perceived loss of Situational low self-esteem r/t actual or perceived loss of

functionfunction

Cerebrovascular AccidentCerebrovascular AccidentNursing GoalsNursing Goals

Maintain stable or improved LOCMaintain stable or improved LOC Attain maximum physical functioningAttain maximum physical functioning Attain maximum self-care activities & skillsAttain maximum self-care activities & skills Maintain stable body functionsMaintain stable body functions Maximize communication abilitiesMaximize communication abilities Maintain adequate nutritionMaintain adequate nutrition Avoid complications of strokeAvoid complications of stroke Maintain effective personal & family copingMaintain effective personal & family coping

Cerebrovascular AccidentCerebrovascular AccidentWarning Signs of StrokeWarning Signs of Stroke

Sudden weakness, paralysis, or numbness of the Sudden weakness, paralysis, or numbness of the face, arm, or leg, especially on one side of the face, arm, or leg, especially on one side of the bodybody

Sudden dimness or loss of vision in one or both Sudden dimness or loss of vision in one or both eyeseyes

Sudden loss of speech, confusion, or difficulty Sudden loss of speech, confusion, or difficulty speaking or understanding speechspeaking or understanding speech

Unexplained sudden dizziness, unsteadiness, loss Unexplained sudden dizziness, unsteadiness, loss of balance, or coordinationof balance, or coordination

Sudden severe headacheSudden severe headache

Cerebrovascular AccidentCerebrovascular AccidentAcute PhaseAcute Phase

AssessAssess:: Frequently to assess CVA evolution Frequently to assess CVA evolutionNeuroNeuro — Glascow Coma Scale -- mental status, LOC, — Glascow Coma Scale -- mental status, LOC,

pupillary response, extremity movement, strength, pupillary response, extremity movement, strength, sensation; ICP; Communication—speaking & sensation; ICP; Communication—speaking & understanding; sensory-perceptual alterationsunderstanding; sensory-perceptual alterations

CVCV– cardiac monitoring; VS, PO, hemodynamic – cardiac monitoring; VS, PO, hemodynamic monitoring; monitoring;

RespResp — airway/air exchange/aspiration; — airway/air exchange/aspiration; GIGI — swallowing—gag reflex; bowel sounds; bowel — swallowing—gag reflex; bowel sounds; bowel

movement regularitymovement regularityGUGU — urinary continence — urinary continenceIntegumentaryIntegumentary — skin integrity, hygiene — skin integrity, hygieneCopingCoping – individual and family – individual and family


Nsg ActionNsg Action:: Supportive CareSupportive Care

Respiratory – spans from intubation to breathing on ownRespiratory – spans from intubation to breathing on own Musculoskeletal -- Positioning – side-to-side; HOB elevated; Musculoskeletal -- Positioning – side-to-side; HOB elevated;

PROM exercise; splints; shoes/footboard PROM exercise; splints; shoes/footboard GI – enteral feedings initially GI – enteral feedings initially GU – foley catheterGU – foley catheter Skin – preventive careSkin – preventive care

Meds: anti plateletMeds: anti platelet


Patient Education:Patient Education:

Clear explanations for all care/treatmentsClear explanations for all care/treatments Focus on improvements—regained abilitiesFocus on improvements—regained abilities Include familyInclude family

Cerebrovascular AccidentCerebrovascular AccidentRehabilitationRehabilitation

Assess: Swallowing; Communication; Assess: Swallowing; Communication; Complications; motor and sensory functionComplications; motor and sensory function

Nsg Action: Coordinate resources:Nsg Action: Coordinate resources: Speech Therapy—assess swallowingSpeech Therapy—assess swallowing Physical Therapy—ambulation/strengtheningPhysical Therapy—ambulation/strengthening Bowel/BladderBowel/Bladder Appropriate self-help resourcesAppropriate self-help resources


Comprehensive plan – Comprehensive plan – Physical Medicine & Rehabilitation / Inpatient RehabPhysical Medicine & Rehabilitation / Inpatient Rehab

Learn techniques to self-monitor & maintain physical Learn techniques to self-monitor & maintain physical wellnesswellness

Demonstrate self-care skillsDemonstrate self-care skills Exhibit problem-solving skills with self-careExhibit problem-solving skills with self-care Avoid complications of strokeAvoid complications of stroke CommunicationCommunication Maintain nutrition & hydrationMaintain nutrition & hydration Use community resourcesUse community resources Family cohesivenessFamily cohesiveness


ResourcesResources American Stroke AssociationAmerican Stroke Association Association of Rehabilitation NursesAssociation of Rehabilitation Nurses National Institute of Neurological Disorders & National Institute of Neurological Disorders &

StrokeStroke National Stroke AssociationNational Stroke Association Society for NeuroscienceSociety for Neuroscience Stroke Clubs InternationalStroke Clubs International

Documents

Cerebrovascular Accident CVA. Cerebrovascular Accident Results from ischemia to a part of the brain or hemorrhage into the brain that results in death