Thrombotic Stroke

Thrombotic Stroke

1. Etiology (Lewis, 2014; The Internet Stroke Center, 2018)

   • Risk Factors
     • Modifiable
       • hypertension
       • Dyslipidemia
       • smoking
       • heart disease
         • atrial fibrilation
         • carotid stenosis
         • myocardial infarction
       • alcohol abuse
       • obesity
       • illicit drug use
         • cocaine
         • heroin
         • methamphetamine
       • sickle cell disease
     • Non-modifiable (higher risk demographics)
       • gender
         • Male
       • Age
         • Older age
       • Race
         • Hispanic
         • African American
         • Asian pacific Islander
       • Genetics/Family history of Stroke

2. Pathophysiology (Lewis, 2014)

   • Sudden interruption of blood flow to the brain
     • ischemic cascade
       • 1. inadequate adenosine triphosphate production
       • 2. loss of ion homeostasis
       • 3. free radical formation
       • 4. release of excitatory amino acids
       • brain damage if cascade is uninterupted
   • Severly reduced blood flow to brain
   • Atherosclerosis
     • Hardening and thickening of cranial artery
       • intimal layer
     • infiltration of lipids in cranial artery
       • Plaque formation
         • common sites for atherosclerosis develop in high turbulence cranial arteries
           • carotid bifurcation
           • innominate artery
           • subclavian artery
           • aorta
         • inflammatory response
           • platelet aggregation
           • fibrin formation

3. Treatment and Prevention (Lewis, 2014)

   • Acute Care Treatment Steps
     • Goals of acute interventions include preserving life, preventing further brain damage, reducing disability
     • 1. Address acute health needs
     • 2. Diagnostic studies
     • 3. Thrombolytic therapy with in 4.5 hrs from symptom onset
   • Medications
     • Tissue plasminogen activator (tPA)
       • Given IV to re-establish blood flow through the blocked artery and reduces cell death. The fibrinolytic action works to lyses the thrombus.
         • Must be given within 4.5 hours of clinical signs. Reduces disability.
           • Client is monitored closely to assess for improvement or deterioration related to hemorrhage.
     • Aspirin 325 mg
       • Given at 24-48 hrs of stroke onset
         • Should be given with caution w peptic ulcer history. Assess for gastrointestinal bleeding
       • 81-325 mg taken routinely once stable
     • Antiplatelets
       • Treatment for preventing subsequent thrombotic strokes, or if presented with past TIAs
         • Plavix (clopidogrel)
         • dipyridamole (persantine)
     • Oral Anticoagulant
       • Warfarin
         • Treatment of choice for client with atrial fibrillation which whom experienced TIAs
   • Surgery
     • Acute
       • Mechanical Embolus Removal Cerebral Ischemia (MERCI)
         • Removes blood clots at site of the stroke
     • Preventative
       • Transluminal angioplasty
         • Balloon insertion to open stenosed artery improving blood flow, permanent stent placed.
       • Artery bypass
         • Anastomosing extracranial artery branch to intracranial artery beyond obstruction, increase perfusion
   • Client Centered Care (Heart and Stroke, 2018)
     • Patient and family teaching for prevention
       • How to identify a stroke
         • FAST
           • Face
             • Is there facial drooping?
           • Arms
             • Can you raise both?
           • Speech
             • Is it slurred or jumbled?
           • Time
             • call 911 right away

4. Clinical Manifestation (Lewis, 2014)

   • Based on what area of brain has infarct. Symptoms tend to present in the first 72 hrs as infarct and edema increases.
   • 1. Altered Motor Function
     • Impaired mobility
       • Alterations in muscle tone and reflexes
         • Reflexes tend to be depressed then hyperactive
     • Reduced swallowing/speech
     • Poor gag reflux
     • Impaired dexterity for self-care
     • Motor skills impaired on opposite side to brain damage
     • Akinesia
   • 2. Communication
     • Aphasia
       • Broca's aphasia (expressive)
         • Can not express thoughts even thought they know what they want to say. Usually only has 4 word vocabulary
       • Wernicke's aphasia (receptive)
         • Difficulty understanding written or spoken language
           • Makes them hard to understand. Words used incorrectly and grammatical errors
       • Anomic aphasia
         • Least sever, person can not find correct name for people, places, things etc
       • Global aphasia
         • Loss of all expression/receptive function. Seen in massive strokes
     • Dysarthria
   • 3. Affect
     • Patient may not control emotions well
       • presenting as unpredictable or exaggerated.
         • Changes with communication/mobility puts them at high risk for depression, very common in the first year.
   • 4. Intellectual Changes
     • Impaired memory/judgement
       • This interferes with learning ability
   • 5. Altered Spatial Perception
     • Anosognosia
       • Happens with damage to parietal lobe.
         • Incorrect perception of self/illness. Client denies illness or body parts
     • Agnosia
       • Inability to recognize an object by sight, touch or sound
     • Apraxia
       • Can not do learned sequential moves
     • Incorrect sense of self within space, can not judge distance or spacial orientation
       • Causes patient to neglect side of body affected by stroke
         • Homonymous hemianopsia
           • Blindness in the same half of the visual fields of both eyes. This worsens perception.
   • 6. patient with left versus right brain damage will present in a predictable manor based on which side is mostly effected.
     • Left Brain Damage
       • Right side paralysis
       • Impaired language
       • Impaired right-left discrimination
       • Slow and cautious movements
       • Aware of deficits
         • Causes anxiety/depression
       • Impaired math and language comprehension
     • Right Brain Damage
       • Left side paralysis
       • Left sided neglect
       • Deficits in spatial perception
       • Denies/minimizes condition
       • Impulsive rapid movements compromising safety
       • Impaired judgement and concept of time
   • Client Centered Care (Guidetti, 2010)
     • Manifestations of stroke=disability in many
       • Client centered self care interventions
         • Improved ADLs
           • Increased client life satisfaction
             • Reduced depression

5. Diagnosis (RSNA, 2018; Musuka et al., 2016)

   • 5. Carotid Ultrasound
     • Doppler Ultrasound
       • checks the two carotid arteries for narrowing and blockages
       • Produces images of blood vessels and information on blood flow
   • 2. MRI
     • powerful magnetic field + Radio frequency pulses + Sophisticated computer
     • produce a detailed pictures of the the head
     • MRA( Magnetic Resonance Angiography): Produces images the cerebral vessels
     • MRP( Magnetic Resonance Perfusion) : Prouces images of blood flow
     • Assess brain damage from stroke
   • 1. Head CT
     • X-ray + Sophisticated computers
     • Used to produce images of inside the head
     • Improves detection and characterization of stroke
   • 6. Blood Tests
   • 3. Cerebral Angiography
     • Performed with three imaging technologies
       • X-ray, CT or MRI
     • Produces pictures of major blood vessels in the brain
     • detects abnormalities
       • Blood clots
       • Narrowing arteries
   • 4. ECG/ EKG
     • Monitors the heart's electrical activity
     • Determines if heart problems caused the stroke

6. Nursing Assessment (RNAO, 2005)

   • 1. Neurological assessments
     • Conducted on admission or when there is a change in status
     • Use a validated tool
       • Canadian neurological scale
       • Glascow coma scale
       • National institute of health stroke scale
   • 2. Vital signs
     • Temp, HR, BP, Resp, O2 sat
   • 3. Pain Assessment
     • Use a validated tool
       • Numeric Rating scale
       • Verbal analogue/ rating scale
   • 5. Nutrition
     • Assess for dysphasia
       • Pt should be maintained as NPO until after assessment
       • Assess and interpret within 24hrs of Pt being awake and alert
       • Includes assessment for
         • Tongue protrusion
         • Wet voice quality
         • Pharyngeal sensation
     • Physical appearance
       • weight loss more than 4.5kg
       • body fat or muscle loss
   • 4. Cognition/perception/language
     • Use validated tools
       • Modified mini-mental state examination
       • Line Bisection test
     • within 48hours of regaining consciousness
   • 6. Bowel and bladder function
     • Assess for Fecal incontinence and constipation
       • due to neurological impairment ?
         • Impaired rectal sensation
         • Inability to voluntary control rectal sphincter
         • Presence of stool in rectal vault
     • Asses for Urinary incontinence and retention
       • measure input and output
     • Physical examination
       • Abdominal assessment
   • 8. Activities of daily living
     • Validated tools
       • Barthel Index
       • Functional Independence measure
     • assess ability to perform ADLs
   • 7. Physical Observation

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