CEREBROVASCULAR DISORDERS

functional ability of the central nervous system that occurs when the normal blood supply to the brain is disrupted.

2 MAIN CATEGORIES:

Ischemic stroke vascular occlusion and significant hypoperfusion occur Hemorrhagic stroke there is extravasations of blood into the brain or subarachnoid space

ISCHEMIC STROKE
brain attack
sudden loss of functional resulting from disruption of the blood supply to the part of the brain.

5 DIFFERENT TYPES: Large artery thrombotic strokes caused by atherosclerotic plaques in the large blood vessels of the brain. Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke. Cardiogenic embolic strokes associated with cardiac dysrhythmias, usually atrial fibrillation Cryptogenic strokes no known cause Strokes from other causes

PATHOPHYSIOLOGY
Cell injury and death Intracellular calcium increased Cell membranes and proteins break down Formation of free radicals Protein production decreased Glutamate Depolarization Ion imbalance Acidosis Energy failure

This is how blood flows through a healthy vessel.

Ischemic stroke can happen when a blood vessel is narrowed due to the build-up of fatty deposits on the walls of the vessel. This can cause blood to collect and clot. Embolic Stroke, a type of ischemic stroke, happens when a wandering blood clot from another part of the body gets stuck in a vessel leading to or in the brain. Such clots often come from diseased areas of the heart. Hemorrhagic Stroke happens when a weakened vessel in the brain bursts, flooding the area with blood. The brain cells die because blood

SIGNS and SYMPTOMS

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 Difficulty walking, dizziness or loss of balance or coordination Sudden severe headache

NEUROLOGIC DEFICITS
Visual Field Deficits Motor Deficits Sensory Deficits Verbal Deficits Cognitive Deficits Emotional Deficits

Visual Deficits
Homonymous Hemianopsia loss of half of the visual field Manifestations: Unaware of persons or objects on side of visual loss.. Neglect of one side of the body. Difficulty judging distances. Nursing Implications/ Patient Teaching Applications: Place objects within intact field of vision. Approach the patient from side of intact field of vision. Instruct/ remind the patient to turn head in the direction of visual loss of compensate for loss of visual field. Encourage the use of eyeglasses if available. When teaching the patient, do so within patients intact visual field. Loss of peripheral vision Manifestation: Difficulty seeing at night. Unaware of objects or the borders of objects. Nursing Implications/ Patient Teaching Applications: Place objects in center of patients intact visual field. Encourage the use of a cane or other object to identify objects in the periphery of the visual field. Driving ability will need to evaluated. Diplopia Manifestation: Double vision. Nursing Implications/ Patient Teaching Applications: Explain to the patient the location of an object when placing it near the patient. Consistently place patient care items in the same location.

Motor Deficits
Hemiparesis Manifestation: Weakness of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere) Nursing Implications/ Patient Teaching Applications: Place objects within the patients reach on the non affected side. Maintain body alignment in functional position. Exercise unaffected limb to increase mobility, strength, and use. Ataxia Manifestation: Staggering, unsteady gait. Unable to keep feet together; need a broad base to stand. Nursing Implications/ Patient Teaching Applications: Support patient during the initial ambulation phase. Provide supportive device for ambulation (walker, cane) Instruct the patient not to walk without assistance or supportive device. Dysarthria Manifestation: Difficulty in forming words Nursing Implications/ Patient Teaching Applications: Provide the patient with alternative methods of communicating. Allow the patient sufficient time to respond to verbal communications. Support patient and family to alleviate frustration related to difficulty in communicating. Dysphagia Manifestation: Difficulty in swallowing Nursing Implications/ Patient Teaching Applications: Test the patients pharyngeal reflexes before offering food and fluids. Assist the patient with meals. Place food on the unaffected side of the mouth. Allow ample time to eat.

Sensory Deficits
Paresthesia (occurs on the side opposite the lesion) Manifestation: Numbness and tingling of extremity. Difficulty with proprioception Nursing Implications/ Patient Teaching Applications: Instruct patient that sensation may be altered. Provide range of motion to affected areas and apply corrective devices as needed.

Verbal Deficits
Expressive aphasia Manifestation: Unable to form words that are understandable; may be able to speak in singleword responses. Nursing Implications/ Patient Teaching Applications: Encourage patient to repeat sounds of the alphabet. Explore the patients ability to write as an alternative means of communication. Receptive aphasia Manifestation: Unable to comprehend the spoken word; can speak but may not make sense. Nursing Implications/ Patient Teaching Applications: Speak slowly and clearly to assist the patient in forming the sounds. Explore the patients ability to read as an alternative means of communication. Global (mixed) aphasia Manifestation: Combination of both receptive and expressive aphasia. Nursing Implications/ Patient Teaching Applications: Speak clearly and in simple sentences; use gestures or pictures when able. When alternative means of communication.

Cognitive deficits
Manifestation: Short and long term memory loss. Decreased attention span. Impaired ability to concentrate. Poor abstract reasoning. Altered judgement. Nursing Implications/ Patient Teaching Applications: Reorient patient to time, place, and situation, frequently. Use verbal and auditory cues to orient patient. Provide familiar objects (family photographs, favorite objects) Use non complicated language. Match visual tasks with a verbal cue; holding a toothbrush, simulate brushing of teeth while saying , I would like you to brush your teeth now Minimize distracting noises and views when teaching the patient. Repeat and reinforce instructions frequently.

Emotional Deficits
Manifestation: Loss of self-control Emotional ability Decreased tolerance to stressful situations Depression Withdrawal Fear, hostility, and anger Feelings of isolation. Nursing Implications/ Patient Teaching Applications: Support patient during uncontrollable outburst. Discuss with the patient and family that the outburst are due to the disease process. Encourage patient to participate in group activity. Provide stimulation for the patient. Control stressful situations, if possible. Provide a safe environment. Encourage patient to express feelings and frustrations related to disease process.

COMPARISON OF LEFT AND RIGHT HEMISPHERE STROKES

LEFT HEMISPHERE Paralysis or weakness on right side of the body Right visual field defects Aphasia Altered intellectual ability Slow, cautious behavior RIGHT HEMISPHERE Paralysis or weakness on left side of the body Left visual field defects Spatial-perceptual deficits Increased distractibility Impulsive behavior and poor judgement Lack of awareness of deficits

ASSESSMENT:
Transient Ischemic Attack (TIA) is a neurologic deficit lasting less than 24 hours, with most episodes resolving in less than 1 hour. sudden loss of motor, sensory, or visual function They occur when a blood clot blocks a vessel for a short period of time may serve as a warning of impending stroke

Angiogram of a transient ischemic attack (TIA)

Courtesy of Intermountain Medical Imaging, Boise, Idaho. Figure 1 shows an angiogram (a type of X-ray) of a normal neck artery (carotid artery) with smooth walls. Figure 2 shows a narrowed carotid artery with ulcerated plaque (the surface of the plaque is irregular and broken) that is the source of clots. The clots travel to the brain and cause TIA symptoms.

MEDICAL MANAGEMENT:
Goal preserve healthy brain tissue surrounding the blockage. This can be accomplished by removing the blockage and restoring blood flow to the area, or by protecting the surrounding tissue. warfarin sodium cardioembolitic stroke aspirin if warfarin is contraindicated platelet- inhibiting medication decrease the incidence of cerebral perfusion 3-hydroxy-2-methyl-glutaryl-coenzyme A reductase inhibitors- to reduce coronary events and strokes THROMBOLYTIC THERAPY dissolving the blood clot that is blocking blood flow to the brain RECOMBINANT t-PA- works by binding to fibrin and converting plasminogen to plasmin

 Angiogram 3D reconstruction showing area of intracranial arterial blockage

CONTRAINDICATIONS:
symptom onset greater than 3 hrs. before admission anticoagulated patient patient with any type of intracranial pathology Criteria for t-PA administration 18 years or older clinical diagnosed ischemic stroke time of onset of stroke known and is 3 hours or less systolic BP <185 mm Hg; diastolic < 110 mm Hg not a minor stroke or rapidly resolving stroke no seizures at onset of stroke not taking warfarin (COUMADIN) prothrombin time <15 seconds or INR < 1.7 not receiving heparin during the past 48 hours with elevated partial thromboplastin time platelet count >100,000/mm3 no prior intracranial hemorrhage, neoplasm, arteriovenosus malformation or aneurysm no major surgical procedures within 14 days no stroke, serious head injury or intracranial surgery within 3 months no gastrointestinal or urinary bleeding within 21 days

 Dosage and administration: dosage for t-PA is 0.9 mg./kg., with a maximum dose of 90 mg. Ten percent of the calculated dose is administered as an IV bolus over 1 minute. The remaining dose (90%) is administered by IV over 1 hour via an infusion pump. Side effect: intracranial bleeding Other treatment: anticoagulant administration (IV) Elevation of head of the bed to promote venous drainage and to lower increased ICP. Intubation with an endotracheal tube to establish a patent airway, if necessary CAROTID ENDATERECTOMY removal of atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries. Indications: TIA or mild stroke CAROTID STENTING less invasive procedure that is used for severe stenosis Complication: stroke, cranial nerve injuries, infection or hematomas and carotid artery disruption

NURSING INTERVENTIONS:
Improve mobility and preventing joint deformities because flexor muscles are stronger than extensor muscles, a posterior splint is applied at night to the affected extremity may prevent flexion and maintain correct positioning during sleep preventing shoulder adduction a pillow is placed in the axilla when there is limited external rotation the arm is placed in a neutral position, with distal joints positioned higher than the more proximal joints helps to prevent edema and resultant fibrosis positioning the hand and fingers volar resting splint can be used to support the wrist and hand in a functional position changing position should be changed every 2 hours to place patient in side-lying position pillow is placed between the legs before the patient is turned to promote venous return and prevent edema, the upper thigh should be acutely flexed if possible, the patient is placed in a prone position for 15-30 minutes several times a day establishing an exercise program to prevent venous stasis performed at least five times daily for 10 minutes at a time. Preparing for ambulation patient is ready to walk as soon as standing is achieved.

Preventing shoulder pain the nurse should never lift the patient by the flaccid shoulder or pull on the affected arm or shoulder range-of-motion exercise antiseizure medication lamotrigine (Lamictal)

Assistive devices to enhance self-care stroke eating devices nonskid to stabilize plates plate guards to prevent food from being pushed off plate wide-grip utensils to accommodate a weak grasp bathing and grooming devices - Long-handled bath sponge grab bars, nonskid mats, hand-held shower heads electric razors with head at 90 degrees to handle shower and tub seats, stationary or on wheel toileting aids raised toilet seat grab bars next to toilet dressing aids Velcro closures elastic shoelaces long-handled shoe horn mobility aids canes, walkers, wheelchairs transfer devices such as transfer boards and belts

HEMORRHAGIC STROKE

15% to 20% of cerebrovascular disorders and are primarily caused by intracranial or subarachnoid hemorrhage. caused by bleeding into the brain tissue, the ventricles or the subarachnoid space. primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension. secondary intracerebral hemorrhage is associated with arteriovenous malformations(AVMs),an intracranial aneurysms, intracranial neoplasms or certain medications(anticoagulants, amphetamines) 43% at 30 days-high mortality rate reported

PATHOPHYSIOLOGY
symptoms are produced when a primary hemorrhage, aneurysm, or AVM presses on nearby cranial nerves or brain tissue or more dramatically when an aneurysm or AVM ruptures, causing subarachnoid hemorrhage

CLINICAL MANIFESTATIONS
severe headache- conscious patient most commonly reports present with a wide variety of neurologic deficits, similar to the patient with ischemic Stroke. comprehensive assessment reveals the extent of the neurologic deficits many of the same motor, sensory, cranial nerve, cognitive and other functions that are disrupted after ischemic stroke are also altered after hemorrhagic stroke.

COMPLICATIONS
Based on assessment data, potential complications may develop include the ff, vasospasm seizures hydrocephalus rebleeding hyponatremia

MEDICAL MANAGEMENT

GOALS allow the brain to recover from the initial result (bleeding) to prevent or minimize the risk for rebleeding prevent or treat complications primarily supportive and consists of bed rest with sedation management of vasospasms surgical or medical treatment Analgesics (codeine, acetaminophen) - for head and neck pain

NURSING INTERVENTIONS
Optimizing Cerebral Tissue Perfusion Relieving Sensory Deprivation and Anxiety Monitoring and Managing Potential Complications Promoting Home and Community Based Care

tHe EnD