CEREBROVASCULAR

ACCIDENT/STROKE
RODNEY R. REYES, RN
EPIDEMIOLOGY

 Stroke is the Philippines' second leading cause of death. (WHO, 2017)

Prevalence:
Ischemic Stroke - 70%
Hemorrhagic Stroke - 30%
 Cerebrovascular disorders are the third leading cause of death in the
United States (Saunders, 2017)
Prevalence:
Ischemic Stroke – 83%
Hemorrhagic Stroke – 17%
EPIDEMIOLOGY

Stroke Survivors

16%
31% Assistance with self care
Assistance with ambulation
Impairment in vocational ability
33% Institutionalized

20%
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
CEREBRAL BLOOD FLOW
DEFINITION

 A stroke, also called a “brain attack”, occurs when a portion of the brain is
damaged due to a lack of blood supply to that part of the brain.
 It is caused by either a blockage (ischemic) or rupture of the blood vessel
(hemorrhagic) in the brain.
 Due to the lack of oxygen and nutrients carried by the blood, brain cells
(called “neurons”) die and the connections between neurons (called
“synapses” or junctions) are lost.
 That part of the brain rapidly loses functions and starts to die.
 The larger area of the damage, the more deficits the patients will have.
TYPES

1. ISCHEMIC STROKE - occur as a result of an obstruction within a blood vessel

supplying blood to the brain.

Subtypes:
a. Thrombotic Stroke
- occurs when an artery becomes blocked by the formation of a blood clot
(thrombus) within it.
- Atherosclerosis is the primary cause wherein fatty material deposit and
form plaques on vessel walls.
- Total blockage may subsequently occur due to clumping together of
blood cells (platelets) or other substances normally found in the blood.
TYPES

Subtypes:
b. Embolic Stroke
- It is the occlusion of a cerebral artery by an embolus that is formed outside
the brain, detaches and travels through the cerebral circulation until it
lodges in and occludes a cerebral artery.
- These materials could be blood clots (e.g. from the heart) or fatty materials
(e.g. from another artery in the neck – carotid artery disease).
- Causes: Chronic atrial fibrillation, mechanical prosthetic heart valves,
bacterial and non bacterial endocarditis, tumor, fat, bacteria and air.
TYPES

2. HEMORRHAGIC STROKE – caused by the rupture of arteriosclerotic and

hypertensive vessels which causes bleeding into brain tissue.
Subtypes:
a. Intracerebral Hemorrhage (ICH) - is most often due to high blood pressure.
The sudden increase in pressure within the brain due to the bleeding can
cause damage to the brain cells surrounding the blood.
b. Subarachnoid Hemorrhage (SAH) - occurs when a blood vessel lying just
outside the brain ruptures. The fluid-filled space surrounding the brain (the
subarachnoid space) rapidly fills with blood.
- It is most often caused by abnormalities of the arteries called aneurysms.
TYPES

 Transient ischemic attack (TIA) — aka “mini stroke” are episodes in which a
person has signs or symptoms of a stroke (e.g, numbness; inability to speak)
that last for a short time, but without any sign of stroke on brain scans such
as MRI or CT.

 Symptoms of a TIA usually last between a few minutes and a few hours. A
person may have one or many TIAs. People recover completely from the
symptoms of a TIA.

 A TIA is a warning sign that a person is at high risk for a stroke; immediate
treatment can decrease or eliminate this risk.
TYPES
Etiology

Modifiable Non-Modifiable
 Blood pressure  Age (> 40 years old)
 Heart disease  Gender (Female > Male)
 Blood cholesterol  Race (African American)
 Diabetes  Genetics
 Clotting problem  Previous stroke
 Cigarette smoking
 Heavy alcohol intake
 Obesity
 Sedentary lifestyle
PATHOPHYSIOLOGY (ISCHEMIC STROKE)
Modifiable Risk Factors Non modifiable Risk Factors

Fatty material deposits and

form plaques on vessel walls
(Atherosclerosis)

Plaques continue to
enlarge(Stenosis)

Altered cerebral blood flow

PATHOPHYSIOLOGY (ISCHEMIC STROKE)

Blood swirls around irregular

surface of the blood vessels

Platelets adhere to the plaques

Blood vessel becomes obstructed

Decreased Cerebral Perfusion

ISCHEMIC STROKE (THROMBOTIC)

 PATHOPHYSIOLOGY (ISCHEMIC STROKE)
Modifiable Risk Factors Non modifiable Risk Factors

Chronic atrial fibrillation Prosthetic heart valves Other causes of

clot/embolus formation
(infection, tumor, fat, air)

Blood pools in poorly Surface is rougher than

emptying atria normal endocardium

Tiny clots form

Increased risk of clot formation
PATHOPHYSIOLOGY (ISCHEMIC STROKE)

Embolus/clots detaches and travels

through cerebral circulation

Occluded cerebral artery

Decreased Cerebral Perfusion

ISCHEMIC STROKE (EMBOLIC)

PATHOPHYSIOLOGY (HEMORRHAGIC STROKE)
Modifiable Risk Factors Non modifiable Risk Factors

Increase blood pressure Weak outpouching blood

vessel wall (Aneurysm)

Rupture of arteriosclerotic
Rupture of aneurysm
and hypertensive vessels

Bleeding into brain tissue

HEMORRHAGIC STROKE
SYMPTOMS
SYMPTOMS

 Face Drooping Does one side of the face droop or is it numb? Ask the
person to smile.
 Arm Weakness Is one arm weak or numb? Ask the person to raise both
arms. Does one arm drift downward?
 Speech Difficulty Is speech slurred, are they unable to speak, or are they
hard to understand? Ask the person to repeat a simple sentence, like "the
sky is blue." Is the sentence repeated correctly?
 Time to call 911 If the person shows any of these symptoms, even if the
symptoms go away, call 9-1-1 and get them to the hospital immediately.
SYMPTOMS

Other clinical manifestations:

 Sudden confusion or trouble understanding

 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of balance or coordination
 Sudden severe headache with no known cause
STROKE ASSESSMENT SCALE

National Institutes of Health Stroke Scale, or NIH Stroke Scale (NIHSS)

 is a tool used by healthcare providers to objectively quantify the
impairment caused by a stroke.
 is composed of 11 items, each of which scores a specific ability between a
0 and 4.
 For each item, a score of 0 typically indicates normal function in that
specific ability, while a higher score is indicative of some level of
impairment.
 The maximum possible score is 42, with the minimum score being a 0.
NIHSS

Score [3] Stroke severity

0 No stroke symptoms

1-4 Minor stroke

5-15 Moderate stroke

16-20 Moderate to severe stroke

21-42 Severe stroke

STROKE ASSESSMENT SCALE

Cincinnati Prehospital Stroke Scale ( CPSS)

is a system used to diagnose a potential stroke in a pre-hospital setting.
It tests three signs for abnormal findings which may indicate that the patient is
having a stroke.
If any one of the three tests shows abnormal findings, the patient may be
having a stroke and should be transported to a hospital as soon as possible.
The CPSS was derived from the National Institutes of Health Stroke
Scale developed in 1997 at the University of Cincinnati Medical Center for
pre-hospital use.[2]
CPSS

 Facial droop: Have the person smile or show his or her teeth. If one side doesn't
move as well as the other so it seems to droop, that could be a sign of a stroke.
 Normal: Both sides of face move equally
 Abnormal: One side of face does not move as well as the other (or at all)
 Arm drift: Have the person close his or her eyes and hold his or her arms straight
out in front with palms facing up for about 10 seconds. If one arm does not
move, or one arm winds up drifting down more than the other, that could be a
sign of a stroke.
 Normal: Both arms move equally or not at all
 Abnormal: One arm does not move, or one arm drifts down compared with the other
side
 Speech: Have the person say, "You can't teach an old dog new tricks," or some
other simple, familiar saying. If the person slurs the words, gets some words
wrong, or is unable to speak, that could be a sign of a stroke.
 Normal: Patient uses correct words with no slurring
 Abnormal: Slurred or inappropriate words or mute
STROKE ASSESSMENT SCALE

The Glasgow Coma Scale (GCS)

 is a neurological scale which aims to give a reliable and objective way of
recording the conscious state of a person for initial as well as subsequent
assessment.
 A patient is assessed against the criteria of the scale, and the resulting
points give a patient score between 3 (indicating deep unconsciousness)
and either or 15 (normal level of consciousness).
GCS

Glasgow Coma Scale [3]

1 2 3 4 5 6

Opens eyes Opens eyes Opens eyes

Does not
Eye in response in response spontaneousl N/A N/A
open eyes
to pain to voice y

Oriented,
Makes no Makes Confused,
Verbal Words converses N/A
sounds sounds disoriented
normally

Abnormal
Extension to Flexion /
flexion to
Makes no painful stimuli Withdrawal Localizes to Obeys
Motor painful stimuli
movements (decerebrate to painful painful stimuli commands
(decorticate
response) stimuli
response)
LABORATORY AND DIAGNOSTIC
PROCEDURES

 Cranial CT Scan: CT scanning combines special x-ray equipment with

sophisticated computers to produce multiple images or pictures of the
inside of the body. Physicians use CT of the head to detect a stroke from a
blood clot or bleeding within the brain.
 LABORATORY AND DIAGNOSTIC
PROCEDURES
 Cranial MRI: MRI uses a powerful
magnetic field, radio frequency pulses
and a computer to produce detailed
pictures of organs and virtually all other
internal body structures.
 MRI is also used to image the cerebral
vessels and cerebral blood flow.
Physicians use MRI of the head to assess
brain damage from a stroke.
LABORATORY AND DIAGNOSTIC
PROCEDURES
 Blood Tests
a. CBC
b. Anticoagulation studies- PT, APTT
c. Blood lipid tests: Cholesterol, total lipids, HDL, and LDL
d. Blood Chemistry – Glucose, Na, K, BUN, Creatinine
e. Homocysteine level tests
f. C- Reactive Protein level tests
LABORATORY AND DIAGNOSTIC
PROCEDURES

 Echocardiogram (ECG) - An echocardiogram uses sound waves to create

detailed images of your heart. An echocardiogram can find a source of
clots in your heart that may have traveled from your heart to your brain
and caused your stroke.
MEDICAL MANAGEMENT

Pillars of Stroke Therapy

1. IV/IA Thrombolysis
2. Thrombectomy
3. Stroke Unit
4. Antiplatelets and anticoagulants
5. Antihyperlipidemic
6. Antihypertensives
7. Decompressive Hemicraniectomy
8. Neurorestoration and neuroprotectants
 MEDICAL MANAGEMENT
(ISCHEMIC STROKE)
Focus: Restore blood flow to the brain
a. Emergency treatment with medications. Therapy with clot-busting drugs
must start within 4.5 hours if they are given into the vein — and the sooner, the
better.
 Intravenous injection of tissue plasminogen activator (tPA)
• This injection of recombinant tissue plasminogen activator (tPA), also
called alteplase, is considered the gold standard treatment for ischemic
stroke.
• An injection of tPA is usually given through a vein in the arm.
• This potent clot-busting drug ideally is given within 3 – 4.5 hours
• This drug restores blood flow by dissolving the blood clot causing your
stroke.
 MEDICAL MANAGEMENT
(ISCHEMIC STROKE)

b. Emergency endovascular procedures. Doctors sometimes treat ischemic

strokes with procedures performed directly inside the blocked blood vessel.

 Intra-arterial thrombolysis - Doctors may insert a long, thin tube (catheter)

through an artery in your groin and thread it to your brain to deliver tPA
directly into the area where the stroke is occurring
 Removing the clot with a stent retriever - beneficial for people with large
clots that can't be completely dissolved with tPA
 MEDICAL MANAGEMENT
(HEMORRHAGIC STROKE)

Focus: Control bleeding and reducing pressure in the brain.

Surgical blood vessel repair. Surgery may be used to repair blood vessel
abnormalities associated with hemorrhagic strokes.
 Surgical clipping. A surgeon places a tiny clamp at the base of the
aneurysm, to stop blood flow to it. This clamp can keep the aneurysm from
bursting, or it can prevent re-bleeding of an aneurysm that has recently
hemorrhaged.
 Coiling (endovascular embolization). A surgeon inserts a catheter into an
artery in your groin and guides it to your brain using X-ray imaging. Tiny
detachable coils are guided into the aneurysm (aneurysm coiling). The
coils fill the aneurysm, which blocks blood flow into the aneurysm and
causes the blood to clot.
 MEDICAL MANAGEMENT
(HEMORRHAGIC STROKE)

Surgical blood vessel repair:

 Surgical AVM removal. Surgeons may remove a smaller AVM if it's located
in an accessible area of your brain, to eliminate the risk of rupture and
lower the risk of hemorrhagic stroke. However, it's not always possible to
remove an AVM if its removal would cause too large a reduction in brain
function, or if it's large or located deep within your brain.
 Stereotactic radiosurgery. Using multiple beams of highly focused
radiation, stereotactic radiosurgery is an advanced minimally invasive
treatment used to repair vascular malformations.
NURSING MANAGEMENT (PREVENTIVE)

 HEALTH EDUCATION

a. DIET - Low-fat, high-fiber, low salt diet

b. EXERCISE - at least 150 minutes (2 hours and 30 minutes) of moderate-
intensity aerobic activity every week (e.g. cycling or fast walking)
c. STOP SMOKING
d. CUT DOWN ON ALCOHOL
NURSING MANAGEMENT (CURATIVE)

1. Use assistive ambulatory devices

 Facilitates ambulation/transfers safely
2. Frequent neurological assessments (per orders)
 Alerts nurse to neurological changes as early as possible, enables them to notify
MD and intervene when needed
3. HOB at 30 degrees unless otherwise indicated
 Increases venous return, decreases ICP
4. Initiate DVT prophylaxis (mechanical and/or chemical)
 Decreases risk for subsequent stroke, as patient most likely will not be as mobile
as they are at baseline
NURSING MANAGEMENT (CURATIVE)

5. Ensure PT/OT/ST is ordered

 Rehab is essential in stroke recovery; all must complete a baseline assessment
and provide recommendations
6. Fall prevention measures (non-skid socks, bed in lowest locked position,
call bell within reach, and so forth)
 Injury prevention; patient will most likely not be able to ambulate as they could
prior to stroke and will require assistance
7. Prevent contractions
 Extremities that are now paralyzed are at risk for becoming contracted; ensure
pillow supports are in place as well as rolled towels and adaptive devices
NURSING MANAGEMENT (CURATIVE)

8. Prevent aspiration: follow ST recommendations, keep HOB at 45 degrees

during oral intake and keep patient upright after a meal, have suction
available, assess lung sounds and body temp
 Stroke patients frequently have impaired swallowing, and are at high risk for
aspiration from their own oral secretions and oral intake.
9. Cluster care; promote rest
 Maximizes time with the patient so they can rest when care is not being
provided
10. Monitor vital signs appropriately; know BP limits
 Closely monitoring BP is essential in managing ICP
NURSING MANAGEMENT (CURATIVE)

11. Prevent edema: elevate limbs, utilize compression stockings, promote

ambulation, promote complete bladder emptying
 Patients who are in bed more will have a harder time clearing fluid out,
especially if they have any underlying heart condition causing a decreased
cardiac output (like atrial fibrillation)
12. Promote self-care
 Patients will have a decreased ability to care for self due to new deficits;
promote confidence and participation in caring for themselves as much as
possible
13. Promote cerebral tissue perfusion (interventions per orders, as this can
differ depending on kind of stroke, location, and other factors)
 This prevents additional neurological damage
NURSING MANAGEMENT (CURATIVE)

14. Facilitate safe swallowing: ensure bedside swallow screening completed

and/or speech therapy assessment prior to oral intake
 Frequently, brain injury results in an impaired ability to swallow safely. This is not
always apparent as patients don’t always cough when aspirating and have
silent aspiration.
15. Promote adequate nutrition
 Once a patient is cleared to eat, do what you can to encourage appropriate
intake… as patients cannot heal if they don’t eat
16. Initiate discharge planning
 Stroke patients typically require multiple needs at discharge (follow up appts,
rehab/therapy, and may need to go to long-term care or inpatient rehab,
depending on the situation) begin getting your mind around their discharge
needs at the beginning even if it’s not clear yet what their needs will be
NURSING MANAGEMENT (CURATIVE)

17. Prevent skin breakdown: turn q2hrs, ensure adequate protein intake, off-
loading, pillow support, keep linen clean and dry
 There are many reasons why a stroke patient will be at risk for skin breakdown…
from an inability to feel or move extremities, incontinence, inability to
communicate needs/pain/discomfort, decreased nutritional status.
18. Facilitate communication; promote family coping and communication
 Having a stroke is a major life event. Roles within families and support systems
may change, especially if the patient played a caregiving role within their
family structure
NURSING MANAGEMENT (REHABILITATIVE)

PHYSICAL ACTIVITIES
 Motor-skill exercises. These exercises can help improve your muscle
strength and coordination. You might have therapy to strengthen your
swallowing.
 Mobility training. You might learn to use mobility aids, such as a walker,
canes, wheelchair or ankle brace. The ankle brace can stabilize and
strengthen your ankle to help support your body's weight while you relearn
to walk.
 Constraint-induced therapy. An unaffected limb is restrained while you
practice moving the affected limb to help improve its function. This
therapy is sometimes called forced-use therapy.
 Range-of-motion therapy. Certain exercises and treatments can ease
muscle tension (spasticity) and help you regain range of motion.
NURSING MANAGEMENT (REHABILITATIVE)

COGNITIVE AND EMOTIONAL ACTIVITIES

 Therapy for cognitive disorders. Occupational therapy and speech
therapy can help you with lost cognitive abilities, such as memory,
processing, problem-solving, social skills, judgment and safety awareness.
 Therapy for communication disorders. Speech therapy can help you
regain lost abilities in speaking, listening, writing and comprehension.
 Psychological evaluation and treatment. Your emotional adjustment might
be tested. You might also have counseling or participate in a support
group.
 Medication. Your doctor might recommend an antidepressant or a
medication that affects alertness, agitation or movement.
PALLIATIVE CARE

 Pain management
 Emotional turmoil and grief
 Physical limitations such as loss of strength or balance
 Nutrition and nutrition disorders caused by stroke
“
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