CEREBROVASCULAR ACCIDENT

Also known as STROKE, or brain infarction A sudden loss of brain function resulting from disruption of the blood supply to a part of the brain Most common site: left middle cerebral artery

Transient ischemic attack (TIA) Is a transient or temporary episode of neurologic dysfunction caused by decreased blood supply to the brain The WARNING SIGN of stroke Most common site: bifurcation of the common carotid artery RISK FACTORS Modifiable: o Hypertension o Heart disease o Diabetes mellitus o Vascular disease o Cigarette smoking Non-modifiable: o Age o Sex or gender o Genetics PATHOPHYSIOLOGY (SIMPLIFIED) ischemic/thromboembolic: Thrombus or embolus blocking the blood supply to a part of the brain sudden interruption of blood supply to the areas of the brain cerebral anoxia and impaired metabolism damage on brain tissues focal neurologic deficit of varying severity hemorrhagic: atherosclerosis arteriosclerosis increase in BP aneurysm rupture ASSESSMENT (depends on artery affected, severity of damage, and extend of collateral circulation): TIA: temporary loss of consciousness, paresthesias, garbled speech RIGHT HEMISPHERE LEFT HEMISPHERE Impulsive Cautious Poor judgment Depressed aphasia

Hemiplegia and sensory deficit CRANIAL NERVES Same side SPINAL NERVES Opposite side Aphasia (impairment communication either in speaking, listening, writing, or comprehending expressive or receptive) Homonymous hemianopsia (opposite of affected part of brain) Unilateral neglect of paralyzed side Bladder impairment Possibly respiratory impairment Impaired mental activity and psychological deficits

MANAGEMENT: 1. Ischemic/thromboembolic a. Approach patient: bad side b. Feed: bad side c. Put sling: bad side d. Put wheel chair: good side e. Cane: good side f. Best position: ABDUCTION 2. Stroke in evolution a. Goal: dissolve/destroy clots with THROMBOLYTICS b. Give within 3 hours of manifestations i. Urokinase ii. Reteplase iii. Alteplase iv. Streptokinase c. Antidote: aminocaproic acid (Amicar) i. Indications: spontaneous bleeding (STOP), bleeding with activity (REPORT) 3. Hemorrhagic a. Initial sx: headache (REPORT!) b. No management, just PREVENTION c. Low fat high fiber (low LDL) d. Eliminate smoking e. Anti hypertensive drugs i. ACE inhibitors prevent RAAS ii. Beta adrenergic blockers reduce catecholamines iii. Calcium channel blockers- for vasospasms iv. Diuretics (osmotic) best drugs for HPN

4. Other managements: a. Management for increased intracranial pressure b. Avoid hypoxia c. Airway patency 5. Drugs: a. Thrombolytics (only for 6 to 8 hrs after clot formation) b. Anticoagulants i. Heparin (SQ) NOT TO HEMORRHAGIC STROKE! 1. For acute cases 2. Check PTT, n = 60-70 seconds 3. Antidote: protamine Sulfate ii. Warfarin (PO) 1. For maintenance 2. Check PT 3. Antidote: Vitamin K c. Antiplatelet: ASPIRIN (PO) d. Nsg responsibilities: i. Check for signs of bleeding ii. Avoid foods that may discolor vomitus, urine, and feces iii. Avoid foods high in Vitamin K (antagonize warfarin) iv. Regular blood exam (PT, PTT) v. Use small gauge needle (g 25 to 28)