Stroke

Stroke

Pathology
1. Cerebral autoregulation
  1. brain needs continuous blood supply for adequate oxygen and glucose for use by neurons
    1. Blood flow disruption
      1. neurological metabolism alters in 30 secs, metabolism stops in 2 mins & cellular death alters 5 mins
      2. Time is brain!!
    2. blood flow must be maintained @ 750-1000mL/min / 20% of cardiac output to function properly
      1. Brain is protected via autoregulation
  2. Factors affecting blood flow
    1. 1/3 reduction in cardiac Output
    2. increased systemic BP causes vasocontstriction vs decreased systemic BP causes vasodilation
    3. increased intracranial pressure may reduce cerebral blood flow to compensate for ICP
    4. Decreased blood viscosity increases flow
2. Etiology
  1. Ischemic Stroke
    1. Uncommon Causes
      1. hypercoagulation state
        Contraception
        APLAS
        Sickle Cell Dx
        Factor V deficit
      2. Cancer; eg. Trusseau Syndrome
      3. Infective endocarditis septic emboli
      4. Vasculitis
    2. Cardioembolic
      1. Patent foramen ovale, left ventricular thrombus, atrial fibrillation
    3. Microvascular DIsease
      1. Lipohyalinosis
    4. Cardiovascular Risk Factors:
      1. Type II Diabetes, Obesity, Smoking, Hypertension, OSA, Dyslipidemia, and Alchohol
    5. Large Artery Artherosclerosis
      1. Intracranial Plaque
        Thrombotic Stroke
        Intracerebral Artery, Middle Cerebral Artery, Anterior Cerebral Artery, Posterior Cerebral Artery
        Embolic Stroke
        Aorta, internal carotid artery, common carotid artery
  2. Intracranial Hemorrhage
    1. Cerebral amyloid angiopathy
      1. B-amyloid plaque deposition on vessel wall, age factor, weak vessel integrity, Alzheimer's disease
    2. Uncommon Causes
      1. Infective endocarditis, septic embolism, vascular tumor, vascular malformation (cerebral aneurism, arterial venous malformation, dural arterial venous fistula, cavernous agnioma
    3. Intracerebral
      1. SLower progression over 24 hours, more fatal if pt is comatose, high risk for women.
    4. Subarachnoid
      1. Highest in women, youngest stroke population
        Thunderclap headache, neck stiffness, and often decreased level of consciousness acute onset
        Risk factors: traumatic brain injury, smoking, high BP, past cerebral aneurism (larger size), family hx of subarachnoid hemorrhage and multiple cerebral aneurisms.
3. Atherosclerosis
  1. Abnormal lipids infiltrate arteries (usually turbulent areas)
    1. Lipids lead to calcified plaques
      1. Calcifications may lead to ruptures that triggers an immune response
        Platelet and fibrin stick to plaque
        Plaque may occlude artery or break off into a thromboembolus
        Leads to cerebral infarction
Treatment
1. Prevention
  1. Non-modifiable
    1. Age (>55), male, African-American, family history
  2. Modifiable
    1. Lifestyle
      1. Incorporate exercise, decrease sodium intake, decrease alcohol consumption, smoking cessation
    2. heart conditions (atrial fibrillation), conditions of coagulability, hypertension, diabetes, obesity
2. Drug Therapy
  1. TIA
    1. antiplatelet medications; ASA (aspirin)
    2. statins; lsimvastatin (zocor), ovastatin
  2. TIA with AF
    1. apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa)
  3. Ischemic
    1. recombinant tissue plasminogen activator (tPA), tPA can place pt at risk of hemorrhage
  4. Hemorrhagic
    1. antihypertensives, seizure prevention
  5. Hemorrhagic (SAH)
    1. Ca channel blockers; nimodipine (Nimotop)
    2. vasodilators; IV milrinone
3. Surgical
  1. TIA
    1. carotid endarterectomy, extracranial-to-intracranial artery bypass, transluminal angioplasty
  2. Ischemic
    1. endovascular treatment (via catheter and wire)
  3. Hemorrhagic
    1. Guglielmi detachable coil
4. Acute Care
  1. Prevent increased ICP
    1. CSF drainage
    2. osmotic agents; mannitol (Osmitrol)
    3. surgical; bone flap removal
    4. seizures; phenytoin (Dilantin), levetiracetam (Keppra),
    5. core body temperature; acetaminophen
  2. assessment and diagnostics within 4.5 hours of admission, airway, breathing, circulation, pt will receive (tPA) within an hour if ischemic, supplemental oxygen (if needed), monitor for neurological deficits, hydralazine, labetolol (if BP >220/120), supplemental IV fluids (monitor electrolytes to avoid hyperglycemia)
5. Rehabilitation
  1. once patient is stable
Diagnostic Studies
1. Other: CSF analysis, Coagulation studies, CBC, Electrolytes, blood glucose, Hb A1C, Lipid profile, renal and hepatic studies
2. Diagnosis of Stroke: CT scan w/t contrast, CT angiography, MRA, MRI
3. Cardiac Assessment: Cardiac markers [Troponin, Creatine-kinase-MB, Chest radiograph, Echocardiography, Electrocardiogram]
4. Cerebral Blood Flow: carotid angiography, carotid duplex scanning, cerebral angiography, digital subtraction angiography, transcranial Doppler ultrasonography
Nursing Management
1. Nursing Diagnoses
  1. risk for aspiration, impaired physical mobility, impaired verbal communication, unilateral neglect, impaired swallowing, impaired urinary eliminatio, situational low self-esteem, decreased intracranial adaptive capacity
2. Nursing Assessment
  1. Primary Assesment:
    1. Subjective Data: Past health history, medications, symptoms (e.g. anorexia, loss of movement/sensation, numbness, alterations in speech...
    2. Objective Data: General, respiratory, cardiovascular, Gastro-intestinal, Urinary, Neruological,
      1. Possible Findings: (+) CT, CTA, MRI; (+) Doppler ultrasonography/angiography indicating stensosis
  2. Secondary Assessment
    1. Comprehensive Neurological Exam - Level of consciousness -cognition -motor abilities -cranial nerve function -sensation -proprioception -cerebellar function -deep tendon reflexes
3. Planning
  1. Patient, Nurse & Family Establish Goals:
    1. Maintain stable/improved LOC, attain maximum physical functioning, attain maximum self-care abilities and skills, maintain stable body functions, maximize communication abilities, maintain adequate nutrition, avoid complications of stroke, maintain effective personal and family coping skills
4. Implementation
  1. Health Promotion, Acute Intervention,
  2. Manage HTN with antihypertensives, control of blood glucose in diabetes cases, treat AF with anticoagulants, smoking cessation,
  3. Neurological
    1. Monitor signs of stroke extension, use of The Canadian Neurological Scale for monitoring, changes in LOC, monitor ICP and cranial perfusion pressure
  4. Respiratory
    1. Decreased muscle strength, risk of atelectasis and pneumonia, dysphagia leading to aspiration pneumonia or airway obstruction, may require enteral feeding and/or artificial airway
  5. Cardiovascular
    1. Manage secondary cardiac diseases, Fluid retention leading to increased ICP (monitor IV fluids, fluid intake and output), Monitor cardiac rhythms, vitals, pulmonary congestion,, orthostatic hypertension, deep-vein thrombosis (ROM exercises, compression devices, low-molecular-weight heparin)
  6. Musculo-Skeletal
    1. Prevent muscular atrophy and joint contractures, ROM exercises, positioning, joints positioned higher than proximal joint (prevent edema), use of slings and splints on extremities
  7. Integumentary
    1. Manage loss of sensation, repositioning (20 minutes per side), cushions, skin hygiene, mobility
  8. Nutrition care outlined by SLP or OT, test of gag reflex, chewing, and swallowing
  9. GI/Urinary
    1. Manage constipation with stool softeners/fibre, laxatives, suppositories, monitor fluid intake,
    2. prevent incontinence, limit use of catheter, adequate fluid intake, scheduled toileting
  10. Patient may experience aphasia, a nurse should speak in simple sentences, use calm tone, and hand gestures or assistive devices
  11. Homonymous hemianopia/neglect syndrome may effect patients ability to interact with the environment
5. Evaluation
  1. Ambulatory & Home Care
    1. Interdisciplinary and family-centered
    2. Eating, toileting & walking, prevention of additional muscle loss, muscle spasticity & regaining voluntary control, balance training, posture control, use of walkers/wheelchairs/splints
    3. Monitor: weight & activity level, signs of malnutrition/dehydration, use of assistive devices. Regular bowel elimination, possibly with the use of stool softener/suppository. Assess: for urinary retention, reduction in the need for incontinence products
    4. Sensory-perceptual deficits require a clear environment and increased use of paralyzed side
    5. Affect & coping should be monitored: look for signs of maladjustment, Patient should begin reintegrating into community
Clinical Manifestations
1. Motor Function
  1. Can have effects: Mobility function, Respiratory function Swallowing, speech, Gag reflex, Self-care abilities
    1. Akinesia
    2. Motor Deficits
      1. Hyper/Hyporeflexia
      2. Akinesia
2. Communication:
  1. Dysarthria -> characterized by slurred or slow speech that can be difficult to understand.
  2. Aphasia
    1. Expressive aphasia, receptive aphasia, global aphasia & anomic aphasia
3. Mood and Affect:
  1. exaggerated or unpredictable emotional responses, frustration and/or depression
4. Spatial-Perceptual: Alterations
  1. Typically associated with right-brain stroke
    1. incorrect perception of self & disease, unilateral neglect, difficulty with spatial orientation, agnosia, apraxia
5. Elimination (temporary)
  1. Urination & BM: Frequency, urgency, incontinence & constipation
6. Patient & Caregiver Teaching Guide
Complications
1. Acute
  1. Dysphagia
    1. Risk for aspiration, airway obstruction
  2. Immobility
    1. DVT, skin breakdown, shoulder-hand syndrome
  3. Neurological
    1. Lack of innervation
      1. Loss of sensation
    2. Intracerebral hemorrhage
      1. Hydrocephalus
        Bleeding into ventricles, brain damage
    3. Hypoxia, hypercarbia, hyperthermia, dehydration, brain damage
    4. Overhydration
      1. Increase in cerebral edema
        Compromised perfusion, brain damage
    5. Increased ICP
      1. Brain herniation, seizures, brain damage, death
    6. Cerebral aneurysm
      1. Subarachnoid Hemorrhage, death
        Rebleeding and Cerebral vasospasm
        Cerebral Infarction
      2. Brain damage
  4. Neglect syndrome, diplopia, homonymous hemianopia, aphasia
2. Post Stroke Comorbidities
  1. Diabetes, hyperglycemia, hypertension, lack of innervation, muscle atrophy, cardiac diseases, respiratory infections, venous thromboembolism, depression, andxiey.
3. Prognosis
  1. Poor regain in functioning if therapy is not started soon after stroke
  2. Thrombotic Stroke
    1. Recurrence
  3. Hemorrhagic stroke
    1. can be fatal, especially if patient fell into a coma first
4. Treatments
  1. Thrombolytic Drugs
    1. Intracranial Hemorrhage, intracranial hemmorrhage, death
  2. Excess heparin
    1. Hemorrhage

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