Med/Surg - Stroke & Aneurysm

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Stroke (CVA)
Neuro deficit due to compromised cerebral blood flow

Neuro deficits vary according to:
- Area of brain involved
- Size of affected area
- Length of time of interrupted blood
flow
Stroke - Incidence & Prevalence
5th leading cause of death

Leading cause of adult disability

Risk increases with age
Doubles for every decade after age 55
2/3 occur in people >65 years of age
Stroke - Non-Modifiable Risk Factors
Age

Heredity

Previous stroke / TIA

Race

Gender
Stroke - Non-Modifiable Risk Factors: Race
African Americans - twice the incidence of any other ethnic group

Hispanics, Asians, Native Americans - higher incidence than whites
Stroke - Non-Modifiable Risk Factors: Gender
Men - more common

Women - higher incidence of death due to stroke
Stroke - Modifiable Risk Factors
Hypertension
Smoking
Diabetes
Heart disease
Atrial fibrillation
Hyperlipidemia & High cholesterol Obesity
Sedentary lifestyle
Ischemic Stroke
Blood supply to a part of the brain suddenly interrupted by a clot or stenosis.

87% of all strokes
Large vessel
Small vessel
Cardiogenic embolic stroke
TIA
Thrombotic Stroke
Caused by occlusion of a cerebral vessel by a thrombus.

Older people who are sleeping/resting

Manifestations:
Aphasia
Neglect syndrome
Visual field defects
No deficit in LOC in first 24 hours
Manifestations progress in first 72
Transient Ischemic Attack (TIA)
Brief period of localized ischemia

Neuro deficits
- Last less than 24°
- Have sudden onset
- Vary according to location & size of
involved vessel
TIA - Includes
Contralateral weakness/numbness of leg, hand, forearm, corner of mouth

Aphasia

Visual disturbances
- Amaurosis Fugax
Embolic Stroke (Cardioembolic)
Of cardiac origin
Atrial Fibrillation
Recent MI

Onset after Valsalva-provoking activity

Worse prognosis than other ischemic strokes
25-30% mortality

Prevention with anticoagulants
Embolic Stroke (Cardioembolic) - Clinical Features
Severe clinical manifestations that appear suddenly

Decreased LOC at onset
Hemorrhagic Stroke
Blood vessel in brain bursts and spills blood into or around the brain
Intracerebral hemorrhage
Subarachnoid hemorrhage

Most fatal
Hemorrhagic Stroke - Manifestations
Vomiting
Headache
Seizures
Hemiplegia
Loss of consciousness
Intracerebral Hemorrhage
Ruptured blood vessel bleeds into brain tissue

Older adults - most common
- Headache may be absent

Hypertension
Subarachnoid Hemorrhage
Blood vessel ruptures near the surface of the brain & leaks into the subarachnoid space

Most are caused by ruptured aneurysm due to head trauma

Younger people - MVA

Older adults - Falls

"the worst headache of my life"
Intracranial Aneurysm
Outpouching of a cerebral artery that occurs at the site of a weakened vessel wall.

Ruptured aneurysm
Most common cause of hemorrhagic
stroke
Adults over age 50, ↑ in women
High mortality rate
Significant complications
Intracranial Aneurysm - Manifestations
silent killer

Sudden & explosive headache
Neck pain/stiffness
Nausea & vomiting
Photophobia
Cranial nerve deficits
Manifestations of Stroke
Vary depending on the area of the brain affected.
Always sudden onset & focal
Usually one sided

Contralateral deficit

Women - nontraditional manifestations
Disorientation
Confusion
Loss of consciousness
Left Side Stroke (Dominant)
Aphasia
Right side weakness/facial droop
Right arm drift
Right visual field loss
Left gaze preference
Right Side Stroke (Non-dominant)
Left side weakness/facial droop
Left arm drift
Left neglect
Left visual field loss
Right gaze preference
Cerebellar Stroke
Normal strength in all extremities

Uncoordinated movements of the limbs or trunk

Difficulty walking, including problems with balance

Abnormal reflexes
Brainstem Stroke
Vertigo

Generalized weakness of all extremities (may have bilateral facial droop and/or bilateral arm drift)

Crossed signs

Dysarthria

Abnormal respirations - Cheyne-Stokes
Stroke - Complications
Sensory-perceptual deficits
Cognitive and behavioral changes
Communication disorders
Motor deficits
Elimination disorders
Sensory-Perceptual Deficits
All senses can be impacted along with ability to sense vibration, pain, temperature, pressure, & proprioception

Hemianopia
Agnosia
Apraxia
Neglect Syndrome
Cognitive & Behavioral Changes
↓ LOC

Behavioral Changes
Emotional lability
Loss of self control
Decreased stress tolerance

Intellectual changes
Memory loss
Decreased attention span
Poor judgement
Inability to think abstractly
Communication Disorders
Result from stroke in the dominant hemisphere (Left)

Disorders in speech - ability to articulate
- Dysarthria

Disorders in language - formulation of ideas to communicate thoughts/feelings
- Aphasia
Motor Deficits - Types of Paralysis
A.Quadriplegia
B.Hemiplegia
C.Paraplegia
Motor Deficits - Hemiparesis
Flaccidity (hypotonia)

Spasticity (hypertonia)
Motor Deficits - Complications of immobility
Orthostatic hypotension
Increased thrombus formation
Decreased cardiac output
Impaired respiratory function
Osteoporosis
Formation of renal calculi
Contractures
Decubitus ulcer formation
Elimination Disorders
Bladder
Urinary frequency
Urgency
Incontinence
Loss of bladder control

Bowel
Result from change in LOC, immobility, & dehydration
Treatment Stages
Stroke prevention

Acute Care
Diagnosing type & cause
Supporting cerebral circulation
Controlling/preventing further deficits

Rehabilitation
The goals of stroke care
Minimize brain injury

Maximize patient recovery
Stroke - Diagnosis
H&P- time of onset

Neuro assessment - NIH Stroke Scale

Imaging - CT scan
Stroke - Diagnosis: Neuro assessment
LOC
Vision
Facial paralysis
Motor abilities
Ataxia
Sensation
Language
Attention
Medication - Prevention
Antiplatelet agents
Used after TIA or previous stroke
A-fib
Aspirin, clopidogrel (Plavix)
Medication - Acute phase: Ischemic Stroke
Goals -
1)prevent further thrombosis 2)increase cerebral blood flow 3)protect cerebral neurons

Fibrinolytic Therapy - tPA
Antiplatelet agents
Anticoagulant Therapy
Fibrinolytic Therapy - tPA
Must be given within 3 hours of onset after CT confirms no hemorrhagic stroke
Antiplatelet agents
Contraindicated in hemorrhagic stroke
Anticoagulant Therapy
Prevent further clot formation but do NOT dissolve existing clot

Warfarin (Coumadin), Heparin, & Enoxaparin
Stroke - Surgery
Prevent stroke occurrence

Restore blood flow

Repair vascular damage/malformations
Stroke - Rehabilitation: PT
Prevent contractures
Build muscle strength
Improve coordination
Improve mobility
Stroke - Rehabilitation: OT
Regain skills that impact ADLs
Stroke - Rehabilitation: Speech Therapy
Language & communication

Swallowing
Stroke - Health Promotion
Smoking cessation
Maintaining healthy weight
Monitor cholesterol
Routine Check-ups
Public Awareness