STROKE

Brain cell function requires a constant delivery of oxygen and glucose from the bloodstream. A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. Blood flow can be compromised by a variety of mechanisms.

Blockage of an artery Narrowing of the small arteries within the braincan cause a lacunar stroke, (lacune means "empty space"). Blockage of a single arteriole can affect a tiny area of brain causing that tissue to die (infarct). Hardening of the arteries (atherosclerosis) leading to the brain. There are four major blood vessels that supply the brain with blood.The anterior circulation of the brain that controls most motor activity, sensation, thought, speech, and emotion is supplied by the carotid arteries. The posterior circulation, which supplies the brainstem and the cerebellum, controlling the automatic parts of brain function and coordination, is supplied by the vertebrobasilar arteries.

If these arteries become narrow as a result of atherosclerosis, plaque or cholesterol, debris can break off and float downstream, clogging the blood supply to a part of the brain. As opposed to lacunar strokes, larger parts of the brain can lose blood supply, and this may produce more symptoms than a lacunar stroke. Embolism to the brain from the heart. In some instances blood clots can form within the heart and the potential exists for them to break off and travel (embolize) to the arteries in the brain and cause a stroke. Rupture of an artery (hemorrhage) Cerebral hemorrhage (bleeding within the brain substance). The most common reason to have bleeding within the brain is uncontrolled high blood pressure. Other situations include aneurysms that leak or rupture or arteriovenous malformations (AVM) in which there is an abnormal collection of blood vessels that are fragile and can bleed.

What causes a stroke? Blockage of an artery The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the brain die and the part of the body that it controls stops working. Typically, a cholesterol plaque in a small blood vessel within the brain that has gradually caused blood vessel narrowing ruptures and starts the process of forming a small blood clot. Risk factors for narrowed blood vessels in the brain are the same as those that cause narrowing blood vessels in the heart and heart attack (myocardial infarction). These risk factors include: high blood pressure (hypertension), high cholesterol, diabetes, and smoking.

Subarachnoid hemorrhage In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the wall of the vessel). Subarachnoid hemorrhages usually cause a sudden, severe headache, nausea, vomiting, light intolerance, and a stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death may occur. Vasculitis Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed causing decreased blood flow to brain tissue. Migraine headache There appears to be a very slight increased occurrence of stroke in people with migraine headache. The mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of function of one side of the body or vision or speech problems. Usually, the symptoms resolve as the headache resolves.

Embolic stroke Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the bloodstream and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of anirregular heart rhythm, such as occurs in atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the blood stream, form a plug (embolism) in a brain artery, and cause a stroke. An embolism can also originate in a large artery (for example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel downstream to clog a small artery within the brain. Cerebral hemorrhage A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke symptoms by depriving blood and oxygen to parts of the brain in a variety of ways. Blood flow is lost to some cells. As well, blood is very irritating and can cause swelling of brain tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes further damage by squeezing the brain against the bony skull further decreasing blood flow to brain tissue and cells.

Who gets stroke? Over age 55 Male A family history of stroke High blood pressure High cholesterol Smoking cigarettes Diabetes Obesity and overweight Cocaine use Heavy use of alcohol

 High blood pressure: The possibility of suffering a stroke can be markedly decreased by controlling the risk factors. The most important risk factor for stroke is high blood pressure. When a person's blood pressure is persistently too high, roughly greater than 130/85, the risk of a stroke increases in proportion to the degree by which the blood pressure is elevated. Managing high blood pressure so that it is well controlled and in the normal range decreases the chances of a stroke. Smoking: An important stroke risk factor is cigarette smoking or other tobacco use. Chemicals in cigarettes are associated with developing atherosclerosis or narrowing of the arteries in the body. This narrowing can involve the large carotid arteries as well as smaller arteries within the brain. Smoking is also a major risk factor in heart disease and artery disease. Diabetes: Diabetes causes the small vessels to close prematurely. When these blood vessels close in the brain, small (lacunar) strokes may occur. Good control of blood sugar is important in decreasing the risk of stroke in people with diabetes. High cholesterol: Elevated cholesterol and/or triglycerides in the bloodstream are risk factors for a stroke due to the eventual blockage of blood vessels (atherosclerosis) and plaque formation. A healthy diet andmedications can help normalize an elevated blood cholesterol level.

What are the symptoms of stroke? Dizziness, trouble walking, loss of balance and coordination Speech problems Numbness, weakness, or paralysis on one side of the body Blurred, blackened, or double vision Sudden severe headache

Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. The loss of voluntary movement and/or sensation may be complete or partial. There may an associated tingling sensation in the affected area. Sudden confusion or trouble speaking or understanding. Sometimes weakness in the muscles of the face can cause drooling. Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause

How is stroke diagnosed? Ultrasound - a wand waved over the carotid arteries in the neck can provide a picture that indicates any narrowing or clotting Arteriography - a catheter is inserted into the arteries to inject a dye that can be picked up by X-rays Computerized tomography: In order to help determine the cause of a suspected stroke, a special X-ray test called a CT scan of the brain is often performed. A CT scan is used to look for bleeding or masses within the brain that may cause symptoms that mimic a stroke, but are not treated with thrombolytic therapy with TPA. MRI scan: Magnetic resonance imaging (MRI) uses magnetic waves rather than X-rays to image the brain. The MRI images are much more detailed than those from CT, but due to the length of time to do the test and lack of availability of the machines in many hospitals, is not a first line test in stroke. While a CT scan may be completed within a few minutes, an MRI may take more than an hour to complete. An MRI may be performed later in the course of patient care if finer details are required for further medical decision making.

 Echocardiograms or ultrasounds of the heart can help evaluate the structure and function of the heart including the heart muscle, valves and the motion of the heart chamber when the heart beats.

What is the treatment of a stroke? Tissue plasminogen activator (TPA) There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain. Heparin and aspirin Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes (see below). In certain patients, aspirin given after the onset of a stroke does have a small, but measurable effect on recovery. The treating doctor will determine the medications to be used based upon a patient's specific needs.

 Carotid endarterectomy: In many cases, a person may suffer a TIA or a stroke that is caused by the narrowing or of the carotid arteries (the major arteries in the neck that supply blood to the brain). If left untreated, patients with these conditions have a higher risk of experiencing a major stroke in the future. An operation that cleans out the carotid artery and restores normal blood flow is known as a carotid endarterectomy. This procedure has been shown to markedly reduce the incidence of a subsequent stroke. In patients who have a narrowed carotid artery, but no symptoms, this operation may be indicated in order to prevent the occurrence of a first stroke.

Nursing Management Nurses will provide safety measures, such as a. Aspiration precautions b. Fall precautions c. Use of restraints d. Seizure precautions Nurses will provide comfort measures, such as: a. Linen changes b. Personal hygiene c. Turning d. Proper positioning e. Range of motion (ROM)

 Nurses will provide a therapeutic environment a. Proper ventilation and lighting b. Minimize noise c. Proper orientation to time, place and person d. Provisions of window murals in every room Nurses will prevent complications and possible infections by: a. Establishing patent airway b. Monitoring and maintaining BP

 Nurses will provide spiritual and psychosocial care: a. Alleviation of anxiety by encouraging verbalization of feelings b. Guidance in identifying positive coping mechanisms c. Respect of patients beliefs and culture d. Facilitation of patients spiritual needs