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STROKE; Cerebrovascular Accident (CVA)

A stroke is caused by a disruption in the normal blood supply to the brain. This disruption
in blood supply may be in the form of interruption in blood flow to the brain, in which
case the stoke is ischemic in origin. The blood supply disruption may also take the form
of bleeding within or around the brain. This is called a hemorrhagic stroke. Formerly
called cerebrovascular accident (CVA), the National Stroke Association now uses the
term brain attack to describe a stroke. A stroke is a medical emergency that strikes
suddenly, and it should be treated immediately to prevent neurologic deficit and
permanent disability. Stroke is the second most cause of death and major disability
worldwide.

Strokes are generally classified as Ischemic and Hemorrhagic. Ischemic strokes are more
common than hemorrhagic stroke, but hemorrhagic strokes are more sever and fatal.

ISCHEMIC STROKE:

An ischemic stroke is caused by the occlusion of a cerebral artery by either a thrombus or

an embolus. A stroke that is caused by a thrombus is referred to as a thrombotic stroke,
whereas a stroke caused by an embolus is referred to as an embolic stroke. About 80% of
all strokes are ischemic.

• Thrombotic Stroke

Thrombotic stroke account for more than half of all strokes and are commonly associated
with the development of atherosclerosis of the blood vessel wall. Atherosclerosis is a
complex process that includes altered function of the inner lining of arterial vessels,
inflammation, and increase growth of smooth muscle cells. It is the process by which
plaques develop on the inner wall of the affected arterial vessel. The bifurcation (point of
division) of the common carotid artery and the vertebral arteries at the junction with the
basilar artery are the most common sites involved. Because of the gradual occlusion of
the arteries, thrombotic strokes tend to have a slow onset.

A lacunar stroke is another type of thrombotic stroke. A lacunar stroke causes a soft area
or cavity to develop in the white matter or deep gray matter of the brain. This type of
stroke may result in significant neurologic dysfunction if it damages a critical area in the
brain.

• Embolic Stroke

An embolic stroke is caused by an embolus or a group of emboli (clots) that breaks off
from one area of the body and travel to the cerebral arteries via carotid artery and
vertebrobasilar system. Te usual source of emboli are cardiac. Emboli can occur in clients
with nonvalvular atrial fibrillation, ischemic heart disease, rheumatic heart disease, and
mural thrombi following a myocardial infarction (MI) or insertion of prosthetic heart
valves. Another source of emboli may be plaques that break off from the carotid sinus or
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internal carotid artery. Emboli tend to be lodge in the smaller cerebral blood vessels at
their point of bifurcation or where the lumen narrows. Embolic strokes account for almost
half of all strokes.

The middle cerebral artery (MCA) is the most common involved in an embolic stroke. As
the emboli occlude the vessel, ischemia develops, and the client experiences the clinical
manifestation of the stroke. However, the occlusion may be temporary if the embolus
breaks into smaller fragment, enter smaller blood vessels, and is absorbed. For these
reasons, embolic strokes are characterized by the sudden development and rapid
occurrence of focal neurologic deficits. The symptoms may be resolved over several
hours or a few days. A cerebral hemorrhage may result if significant damage to the wall
of the involved vessels has occurred. Conversion of an occlusive stroke to a hemorrhage
stroke may occur because the arterial vessel wall is also vulnerable to ischemic damage
from blood supply interruption. Sudden hemodynamic stress may result in vessel rapture,
causing bleeding directly within the brain tissue.

Transient Ischemic Attack (TIA) and Reversible Ischemic Neurologic Deficit (RIND)

• TIA and RIND are the preceding signs of Ischemic stroke.

• TIA is also called “silent stroke”
• Both cause transient focal neurologic dysfunction resulting from cerebral
vasospasm or transient systemic arterial hypertension.
• The difference between a TIA and an RIND is the length of time the client is
symptomatic.
• TIA last a few minutes to fewer than 24 hours.
• RIND symptoms last longer than 24 hours, but less than a week.
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• Both may damage brain tissue with repeated insult.

HEMORRHAGIC STROKE

The second major classification of stroke is hemorrhagic stroke. In this type of stroke
vessel integrity is interrupted, and bleeding occurs into the brain tissue or into the spaces
surrounding the brain. (ventricular, subdural, subarachnoid). Hemorrhage into the brain
generally results from a rapture aneurysm; rapture of an anteriovenous malformation; or,
more commonly, sever hypertension.

• Aneurism

A ruptured cerebral aneurysm results in

hemorrhagic stroke. An aneurism is an
abnormal ballooning or blistering on the
involved artery. Aneurysm may be
congenital or traumatic. In congenital
aneurism, there is a weakened vessel
wall. Continued force on the weakened
vessel wall from elevated blood pressure
stretches and thins the vessel wall,
causing the innermost vessel layer to
protrude. Rapture of the blood vessel can
occur during activity. Aneurysms are
most often found at the bifurcations of
major cerebral arteries.

Aneurysm rapture causes the

development of an intracerebral
hematoma, bleeding into the
subarachnoid space, or bleeding directly
into the ventricles. Vasospasm, a sudden
and transient constriction of a cerebral
artery, often occurs after a cerebral
hemorrhage from aneurysm rapture. This
occurs because blood is also an irritant
to arterial vessels. Blood flow to distal
areas of the brain supplied by the artery
is markedly diminished, which leads to
cerebral ischemia and infarctions and
further neurologic dysfunction.
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• Anteriovenous Malformation thinned wall veins are subjected to

arterial pressure.
AVM is a developmental abnormality
that occurs during embryonic
development. It is a tangled or spaghetti-
like mass of malformed, thin-walled
dilated vessels. A congenital absence of
capillary network forms an abnormal
communication between the arterial and
venous systems. The vessels may
eventually rapture, causing bleeding into
the subarachnoid space or into the
intracerebral tissue. The risk of rapture
and cerebral hemorrhage exist because
normally the capillary network, the

• Hypertension

Although the exact mechanism involved are unknown, it is hypothesized that elevated
systolic and diastolic blood pressures cause changes within the arterial wall that leave it
susceptible to rapture. An intracerebral hemorrhage when the vessel raptures. Damage to
the brain occurs from bleeding, causing distortion or displacement. Brain tissue edema
acts as a direct irritant to brain tissue. Hemorrhagic stroke may be more likely with
sudden, dramatic blood pressure elevations, such as those seen with cocaine intoxication.

The picture above shows massive hypertensive hemorrhage in the brain.

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Common, Etiologic, and Genetic Risk

• Black Heritage
• Hypertension • Sickle cell anemia
• Type II Diabetes • Sudden discontinuation of
• Heart Disease antihypertensive medications
• Hypercholesterolemia • Nonvalvular Atrial Fibrilation.
• Hypercoagulable (increase • Heart mumur or atrial fibrillation
clotting) state • MI
• Illicit drugs (especially cocaine) • Previous stroke or TIA
• Obesity • Vavular heart Disease
• Heavy alcohol use • Smoking
• Migraines • Sedentary lifestyle
• Older age • Oral contraceptive use
• Male

Signs and Symptoms of CVA

Signs

• Sudden weakness, numbness, or paralysis of the face, arm or leg, on one or both
sides of the body.
• Sudden blurred vision or blindness in one or both eyes.
• Sudden difficulty speaking, slurring of speech or difficulty understanding.
• Sudden severe headache with sudden onset that occurs without apparent reasons.
• Sudden loss of balance, dizziness, or falling without any apparent reason.

Symptoms

Symptoms Depends on what side of the brain is affected.

Feature Left Hemisphere Right Hemisphere

Language Aphasia Impaired sense of humor
 Wernicke's aphasia
 Broca's aphasia
 Global aphasia
Agraphia
Alexia (word blindness)
Memory Possible deficit Disorientation to time,
place, and person.
Inability to recognize faces.
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Vision Inability to discriminate Visual spatial deficits

words and letters. Neglect of the left visual
Reading problems field.
Deficit in the right visual Loss of depth perception.
field.
Behavior Slowness Impulsive
Cautiousness Lack of awareness of
Anxiety when attempting a neurologic deficits.
new task. Confabulation
Depression or a catastrophic Euphoria
response to illness. Constant smiling
Sense of guilt Denial of illness
Feeling of worthlessness. Poor judgment
Worries over future. Overestimation of abilities
Quick anger and frustration. (risk for injuries)
Intellectual impairment.
Hearing No deficit Loss of ability to hear tonal
variations.

Diagnostic Procedures

• Blood Tests - including a complete blood count, blood sugar, cholesterol, fat
levels, clotting levels, and a check of other elements in the blood

• Electrocardiogram (EKG) – to measure heart rhythm and check for an irregular

heart beat

• Ultrasound– a test that uses sound waves to help determine if there are blockages
in the arteries supplying the brain

• MRI Scan – a test that uses magnetic waves to make pictures of structures inside
the head

• CT Scan – a type of x-ray that uses a computer to make pictures of structures

inside the head

• Magnetic Resonance Angiography – performed prior to carotid artery surgery to

determine how much the artery has narrowed. Gadolinium, a type of dye, may be
injected into your vein for this test.

• Arteriogram - during a conventional arteriogram, a contrast dye is injected and

x-ray images are produced to precisely locate the blockage and to determine how
much of the artery is blocked. This test is usually only done to confirm the need
for surgery.
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• Echocardiogram - an ultrasound test that looks for blood clots and valve
abnormalities within the heart

• Electroencephalogram (EEG) - a test that can detect seizures by measuring

brain waves (used only if a seizure is suspected)

Surgical Management

• Endarterectomy – purpose is to remove the atherosclerotic plaque from the inner

lining of the carotid artery.
• Extracranial-Incracranial Bypass – bypasses the blocked artery by making a
graft or a bypass from the first artery to the second artery.
• Management Of Anteriovenous Malformation - is an interventional therapy to
occlude abnormal arteries or veins and prevent bleeding from the vascular lesions.
Whenever possible the affected vessels are totally removed. The surgeon ligates
the vessels and removes the defect.
• Management of Cerebral Aneurism – Aneurysm may be repaired via
craniotomy. Less invasive procedure is interventional Radiology
• Management of Intracranial Bleeding – Blood clots are removed via
craniotomy.

Other Medical Management:

Medical Management

a. Steroids/corticosteroids given in full stomach with antacid or H2 receptor

antagonists
b. Vitamin B complex – promote restitution of function of neurons which have
reversible damage.
c. Cerebral activator/stimulants – stimulate CNS function.
• nootrophil- PIRACETAM
• encephabol- PYRITINOL HCl
• hydergine- CODERGOCRIN
d. Drugs if it is due to thrombus, give ANTI-COAGULANT

• heparin- HEPARIN SODIUM

• coamadin- WARFARIN SODIUM

e. Drugs if it due to hemorrhage with large hematoma

Nursing Managements
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A. Initial nursing objective is to support life and prevent complications.

B. Maintain patient airway and ventilation--- elevate head of bed 20 degrees unless
shock is present.

C. Monitor clinical status to prevent complications.

1. Neurological
a. Include assessment of recurrent CVA, increased intracranial
pressure, hyperthermia.
b. Continued coma--- negative prognostic’ sign
2. Cardiovascular--- shock and arrhythmias, hypertension.
3. Lungs--- Pulmonary emboli.

D. Maintain optimal positioning.

1. During acute stages, quiet environment and minimal handling to prevent
further bleeding.
2. Upper motor lesion--- spastic paralysis, flexion deformities, external rotation
of hip.
3. Position schedule--- 2hours on unaffected side, 20minutes on affected side.
4. Complications common with hemiplegia--- frozen shoulder, footdrop.

E. Maintain skin integrity: turn and provide skin care.

F. Maintain personal hygiene: encourage self-help.

G. Promote adequate nutrition, fluid, and electrolyte balance.

1. Encourage self-feeding.
2. Food should be placed in unparalyzed side of mouth.
3. Tube feedings or gastrostomy feeding may be necessary.

H. Administer tube feedings.

I. Promote elimination.
1. Bladder control may be regained within three to five days.
2. Retention catheter may not be part of treatment regimen.
3. Offer urinal or bedpan every two hours day and night.

J. Provide emotional support.

1. Behavior changes as consciousness is regained--- loss of memory, emotional
liability, confusion, language disorders.
2. Reorient, reassure, and establish means of communication.

K. Promote rehabilitation to maximal functioning.

1. Comprehensive program--- begins during acute phase and follows through
convalescence.
2. Guidelines to assist client with lesion left hemisphere.
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a. Do not underestimate ability to learn.

b. Assess ability to understand speech.
c. Act out, pantomime communication; use client’s term to
communicate; speak in normal tone of voice.
d. Divide tasks into simple terms; give frequent feedback.
e.
3. Guidelines to assist client with lesion right hemisphere.
a. Do not overestimate abilities.
b. Use verbal cues as demonstrations; pantomimes may confuse.
c. Use slow, minimal movements and avoid clutter around client.
d. Divide tasks into simple steps; elicit return demonstration of skills.
e. Promote awareness of body and environment on affected side.
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Precipitating Factors: PATHOPHYSIOLOGY

Hypertension Predisposing Factors:
Hyperlipidemia Life style (sedentary)
Diabetes Mellitus VASOCONSTRICTION Vices (Alcohol, smoke)
Heart Diseases Age
Atherosclerosis Diet
Arteriosclerosis Sex
Thrombosis Heredity
Severe dehydration Blockage of the blood Self-medication
vessel
Embolism

Lack of oxygen & High blood pressure, smoking, heart

Ischemic diseases, diabetes, narrowing of arteries
nutrients supply supplying the brain, high cholesterol and
Stroke an unhealthy lifestyle.

Cerebral Ischemia Hypoxia

High blood pressure, smoking, and a
Subarachnoid
family history of burst aneurysms.
Hemorrhage
- Cell death Altered cerebral
- Decreased metabolism Severe dehydration, severe infection in
Oxygen level the sinuses of the head and medical or
Venous Stroke genetic conditions that increase a person’s
tendency to form blood clots.
Intracerebral Decreased cerebral
hemorrhage perfusion
Large Artery Hypertension, diabetes, smoking and high
Strokes cholesterol levels.

Local
P Acidosis
A Transient
R Ischemic Same with Ischemic stroke
Attack
A Cytotoxic
L Edema

Y Small Artery Hypertension, diabetes and

S Aneurysm
Stroke smoking.

I Rupture
S Irregular heart beat (atrial fibrillation), a
Embolic heart attack (myocardial infarction), heart
strokes failure or a small hole in the heart called a
PFO (Patent Foramen Ovale).

Brain tissue
Necrosis

DEATH Severe Cases

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The Human Brain