CEREBRO -VASCULAR ACCIDENT Cerebrovascular disorders” is an umbrella term that refers to any functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. An ischemic stroke, cerebrovascular accident (CVA), or what is now being termed “brain attack" is a sudden loss of function resulting from disruption of the blood supply to a part of the brain, This event is usually the result of long-standing cerebrovascular disease. Ischemic strokes are subdivided into five different types according to their cause: © Large artery thrombosis (20%) * Small penetrating artery thrombosis (25%) ‘© Cardiogenic embolic stroke (20%) © Cryptogenic (3054) and © Other (5%) DEFINITIO “Brain attack” is a sudden loss of function resulting from disruption of the blood supply toa part of the brain - Brunner and Suddharth, Astroke is an interruption of blood supply to any part of the brain resulting in a sudden loss of brain function + Javed Ansari ‘The sudden death af some brain ceils due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain - Medical dictionary ‘CAUSES AND RISK FACTORS: Y Transient ischemic attack Cerebral thrombosis Cerebral embolism Cryptogenic Cerebral haemorrhage Cerebral aneurysm Arteriovenous malformation R046 66RISK FACTORS: Hypertension ¥ Cardiovascular disease (cerebral emboli may originate in the heart) Y Atrial fibrillation Y Coronary artery disease Y Heart failure ¥ Left ventricular hypertrophy ¥ Myocardial infarction (especially anterior) Rheumatic heart disease High cholesterol levels ¥ Obesity Y Diabetes mellitus Oral contraceptive use ¥ Smoking Y Drug abuse Excessive alcohol consumption PATHOPHYSIOLOGY: Disruption of the cerebral blood flow due to obstruction of a blood vessel. | Initiates a complex series of cellular metabolic events referred to as the ischemic cascade (The ischemic cascade begins when cerebral blood flow falls to less than 25 mL/100 g/min) J At this point, neurons can no longer maintain aerobic respiration. J ‘The mitochondria then switch to anaerobic respiration, which generates large amounts of lactic acid J causing a change in the pH level and less production of adenosine triphosphate (ATP) to fuel the depolarization processes | electrolyte balances begin to fail, and the cells cease to function J cell deathEarly in the cascade, an area of low cerebral blood flow, referred to as the penumbra region, exists around the area of infarction. The penumbra region is ischemic brain tissue that can be salvaged with timely intervention, The penumbra area can be revitalized by administration of tissue plasminogen activator (t-PA), and the influx of calcium can be limited with the use of cafcium channel blockers, ISCHEMIC STROKE PATHOPHYSIOLOGY The First Few Hours “TIME IS BRAIN: SAVE THE PENUMBRA” Penumbra is zone of reversible ischemia around core of irreversible infarction—salvageable in first few hours after ischemic stroke onset Penumbra damaged by: ‘+ Hypoperfusion + Hyperglycemia * Fever * Seizure CLINICAL MANIFESTATIONS: © Numbness or weakness of the face, arm, or leg, especially on one side of the body Confusion or change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty walking, dizziness, or loss of balance or coordination oo00 ‘Sudden severe headache Disruption of Motor, sensory, cranial nerve, cognitive, and other functions Loss of peripheral vision Diplopia Hemiparesis Hemiplegia oo0e000‘Aphasia Ataxia Dysarthria Dysphagia Apraxia Hemianopsia oeooco DIAGNOSTIC FINDINGS: History collection ‘Complete physical and neurologic examination Non-contrast computed tomography (CT) sean 12-lead electrocardiogram Carotid ultrasound ‘Cerebral angiography Transcranial Doppler flow studies Trans-tharaci¢ or trans-esophageal echocardiography Magnetic resonance imaging of the brain and neck Xenon CT and single photon emission CT ooocec0v0000 PHARMACOLOGIC THERAPY: 1, THROMBOLYTIC THERAPY; Recombinant t-plasminogen activator (It works by binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the atherosclerotic lesion) 2. Anticoagulant administration: IV heparin or low-molecular weight heparin 3, Anti-platelets: Aspirin, Clopidogrel and Ticlonidine 4, Osmotic diuretic; Mannitol (to reduce ICP) Therapy for Patienty with Ischemic Stroke Not Receting T-PA »& Elevation of the head of the bed to promote venous drainage and to lower increased ICP «& Supplemental oxygen is often provided. s+ Intubation with an endotracheal tube to establish a patent airway, if necessary + Continuous hemodynamic monitoring. Systolic pressure should be maintained at less than 180 mm Hg, diastolic pressure at less than 100 mm Hg. s+ Maintaining the blood pressure within this range reduces the potential for additional bleeding or further ischemic damage. "& Neurologic assessment to determine whether the stroke is evolving or whether other acute complications are developing, such as bleeding from anticoagulationfor medication induced bradycardia, which can result in hypotension and subsequent decreases in SURGICAL MANAGEMENT: 1. ENDARTERECTOMY: © The main surgical procedure for managing TIAs and small stroke is carotid endarterectomy, © Acarotid endarterectomy is the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries Indication: © This surgery Is indicated for patients with symptoms of TIA or mild stroke found to be due to severe (70% to 99%) carotid artery stenosis or moderate (50% to 69%) stenosis with other significant risk factors NURSING MANAGEMENT: The patient who has had a stroke is at risk for multiple complications, including deconditioning and other musculoskeletal problems, swallowing difficulties, bowel and bladder dysfunction, inability to perform self-care, and skin breakdown. After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits. Assemment, During the acute phase, a neurologic flow sheet is maintained to provide data about the following important measures of the patient's clinical status: * Change in the level of consciousness or responsiveness * Presence or absence of voluntary or Involuntary movements © Stiffness or flaccidity of the neck, eye opening, comparative size of pupils and pupillary reactions to light, and ocular position * Colour of the face and extremities, temperature and moisture of the skin © Quality and rates of pulse and respiration © Ability to speak * Volume of fluids ingested or administered and volume of urine excreted each 24 hours * Presence of bleeding After the acute phase, the nurse assessesMental status Sensation Motor control ‘Swallowing ability Nutritional and hydration status Skin integrity Activity tolerance and Bowel and bladder function, Ongoing nursing assessment continues to focus on any impairment of function in the patient’s daily activities, because the quality of life after stroke is closely related to the patient’s functional status. NURSING DIAGNOSES: Based on the assessment data, the major nursing diagnoses for a patient with a stroke may include; 1, Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury 2. Acute pain related to hemiplegia and disuse related to stroke sequelae Self- care deficits related to stroke sequelae 3. Disturbed sensory perception related to altered sensory reception, transmission, and/or integration 4. Impaired swallowing related to loss of sensation 5. Incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating 6. Disturbed thought processes related to brain damage, confusion, or inability to: follow instructions 7. Impaired verbal communication related to brain damage 8. Risk for impaired skin integrity related to hemiparesis/ hemiplegia, or decreased mobility 9. Interrupted family processes related to catastrophic illness and caregiving burdens 10. Sexual dysfunction related to neurologic deficits or fear of failure