Cerebrovascular Accident

CEREBROVASCULAR
ACCIDENT
Dr. Jayesh Patidar
www.drjayeshpatidar.blogspot.com
PATIENT PRESENTATION-
1
Mr.X,67yrs
C/O weakness of RUL and RLL for 10 days
C/O slurred speech for 10 days
K/C/O T2 DM and on treatment
(uncontrolled)
K/C/O systemic hypertension
H/O lt leg diabetic foot below great toe
H/O IHD
9/15/2014 2 www.drjayeshpatidar.blogspot.com
Assessment
O/E conscious, obeying commands
Speech dysarthria
EOM-restricted
Right facial palsy, gag reflex(N)
Motor-hemiplegia
Sensory-pain/touch impaired on right side
DTR-++/++
No neck stiffness
Investigations
urine for c/s-no growth
ECG: normal sinus rhythm
Blood investigations
Cholesterol-294(200)
Triglyceride-129(150)
HDL-25/11.8(60)
LDL-201(100-159)
MRI-Acute infarct in the medial aspect of
pons
Age related atrophic changes
BP-150/90 mmhg
HR-98b/mt
Spo2-100
RR-30b/mt
Temp-98.6 f
Medications
Inj. Clexane 0.4ml s/c od
Inj. Magnex forte 1.5gm in 100ml NS
IV bd
Inj. Rantac 50mg IV bd
Inj. H.Actrapid according to CBG s/c
tds
T. Clopitab 75 mg RT 0-1-0
T. Nicardia R 10 mg RT 1-0-1
2
Mr. Y 60/m
C/O neck pain x 4 days
H/O fever x 2 days, low grade
H/O one episode of giddiness x vomiting,
slurring of speech
Pain and touch impaired on the right side
Known HTN x 5yrs
Lt eye ptosis, nystagmus-gaze evoked
ataxia, ltUL-4/5 RUL-5/5
Assessment
BP-140/80 mmhg
HR-92b/mt
Spo2-99%
RR-20breaths/mt
Temp-98.6 f
Medications
Inj. Fraseda 30 mg IV 100ml NS
Inj. Rantac 50 mg IV
Inj. Strocit 500 mg IV
T Clopilet 75 mg p/o 0-1-0
T Atorva 10 mg p/o 0-0-1
Investigations
RBS-177 PPBS-141
Na- 130
Cholesterol-239
Triglyceride-207
HDL-31/7.7
LDL-177
MRI-Sub acute infarct
Chronic infarct-rt cerebellum
Carotid Doppler- Carotid grade II intimal
changes
Non visualization of the mid and distal
portion of the basilar artery with very thin
caliber vertebral arteries.
Vertebral Doppler study-lt vertebral minimal
flow, rt vertebral normal
3
Mr.Z,40yrs/M
Rt MCA infarct
C/O weakness of LUL and LL for 4 days
H/O slurring of speech
Mouth deviating to rt side
Chronic smoker and alcoholic-25yrs
BP 150/80 mmhg
Lt-UL:0/5,LL-0/5
rt- UL:5/5,LL-5/5
Assessment
GCS:15/15
Pupils:2mm reacting to light
Reflexes:++/++
Alk phophatase:105
Cholesterol-155
Triglycerides-112
HDL-35
LDL-98
CT brain: Acute infarct-Rt MCA territory
MRI: Rt MCA infarct
Medications
T.Nicardia R 10mg p/o tds
T.clopilet 75 mg p/o od
T.Statin 10 mg p/o od
Inj Fraseda 30mg in 100ml Ns IV bd
Inj Neksium 70 mg IV bd
15
What is a Stroke?
Stroke is a term used to describe
neurological changes lasting more
than 24 hours caused by an
interruption in the blood supply to a
part of the brain. If the blood flow
ceases for an extended period of time,
the cerebral tissues involved die
causing permanent neurological
deficits.
CEREBRAL CIRCULATION
17
LOCATION
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18009.htm
CLINICAL MANIFESTATIONS
COMMON EFFECTS OF A RIGHT HEMISPERIC STROKE
Left visual field loss (homonymous hemianopsia)
Dysphagia
Usually retain language ability but may have difficulty producing speech
(dysarthria)
Left-sided weakness (hemi paresis) or paralysis (hemiplegia)
Sensory impairment
Denial of paralysis, forget or ignore objects or people on their left side
(neglect)
Impaired ability to judge spatial relationships (misjudge distances and depth
leading to falls, unable to guide hands to button a shirt, problems with directions
such as up / down, no concept of time)
Impaired ability to locate and identify body parts
Short-term memory impairments (difficulty remembering new information) and
apraxia(inability to carry out learned movement in the absence of weakness or
paralysis)
Behavioral changes such as impaired judgement or insight into limitations,
overestimate physical ability, impulsivity, inappropriateness and difficulty
comprehending and expressing emotions
COMMON EFFECTS OF A LEFT HEMISPERIC
STROKE
Right visual field loss (homonymous hemianopsia)
Dysphagia
May develop aphasia (loss of language including spoken, written,
reading and comprehension) but may also have dysarthria
Right-sided weakness (hemiparesis) or paralysis
(hemiplegia)
Sensory impairment
Usually have normal perception
Usually judgement is intact with good insight into
limitations
Short-term memory impairments (difficulty remembering
new information) and apraxia (inability to carry out learned
movement in the absence of weakness or paralysis)
Often develop a slow and cautious behavioral style. They need
frequent instructions and feedback to complete tasks
Better able to comprehend and express emotions
TYPES OF STROKE
Ischemic 80 - 84%
Caused by blockage of the
artery resulting in reduction of
blood flow and cell death
Include thrombotic, lacunar,
embolic cryptogenic
CT scan negative until a few
days post stroke then
hypodense area - indicates
infarction
THROMBOTIC STROKE
Atherosclerosis in cerebral arteries
Similar to CAD leading to MI
Atherogenesis decades long process
In thrombotic stroke lumen of artery
narrows to point of obstruction
LACUNAR STROKE
Atherosclerosis in
cerebral arteries
Similar to CAD
leading to MI
Atherogenesis
decades long process
In thrombotic stroke
lumen of artery
narrows to point of
obstruction
EMBOLIC STROKE
A clot travels from source outside of brain
Encounters vessel with lumen narrow
enough to block its passage
Clot lodges there, blocking blood flow
Most common source - heart
Common conditions - atrial fibrillation,
valvular disease, ventricular thrombi,
atherosclerosis of the proximal aorta
HEMORRHAGIC STROKE
A clot travels from source
outside of brain
Encounters vessel with lumen
narrow enough to block its
passage
Clot lodges there, blocking
blood flow
Most common source - heart
Common conditions - atrial
fibrillation, valvular disease,
ventricular thrombi,
atherosclerosis of the proximal
aorta
EMERGENCY
MANAGEMENT
Neurological vital
signs
Blood pressure
Glycemic control
Control of body
temperature
Oxygenation
Hydration
HEMORRHAGIC STROKE
Treatment based on the underlying cause of
the bleed and the extent of brain damage
Treatment includes medication and surgical
intervention
Management of ICP with
antihypertensives or surgical evacuation of
hematoma
In patients with ruptured aneurysm - clip or
embolization
Strategies to prevent a stroke
-Maintain a healthy weight - eat a reduced-fat diet
Reduce alcohol intake to 1-2 drinks / day
Exercise - 30 minutes 3-4 times / week
Become smoke free and drug free
Management of hypertension (ACE inhibitors)
Management of heart disease (anticoagulants), diabetes
and hyperlipidemia (statins)
Carotid endarterectomy may be indicated with stenosis
Antiplatelets for plaque / clot formation
NURSING DIAGNOSIS
Ineffective tissue perfusion r/t decreased cerebral
blood flow or cerebral edema
Ineffective airway clearance r/t inability to raise
secretions ,ineffective cough
Impaired physical mobility r/t neuromuscular and
cognitive impairment, decreased muscle strength
and control
Impaired verbal communication r/t residual aphasia
Risk for aspiration r/t inability to protect the airway
Altered sensory perceptual r/t altered LOC,
impaired sensation and vision.
Unilateral neglect r/t visual field deficit and
sensory loss on one side of the body
Impaired urinary elimination r/t impaired
impulse to void or manage tasks of voiding
Impaired swallowing r/t weakness or
paralysis of affected muscles
Situational low self esteem r/t actual or
perceived loss of function.
NURSING MANAGEMENT
Airway management/ventilator management
Assessment and evaluation of neurologic
status to detect patient deterioration
Blood pressure management
General supportive care and prevention of
complications associated with:
Dysphagia, HTN, hyperglycemia, dehydration,
malnourishment, fever, cerebral edema,
infection, and DVT, immobility, falls, skin care,
bowel and bladder dysfunction.
SIGNS OF ICP
Early signs:
Decreased LOC
Deterioration in
motor function
Headache
Changes in vital
signs
Late signs
Pupillary
abnormalities
Changes in
respiratory pattern
Changes in ABGs
Airway management adequate O2 saturation
Preventing increased ICP and providing supportive
care.
Hourly vitals/neuros including ICP, CPP, CVP.
Maintaining BP to ensure adequate CPP
Seizure precautions
Antibiotic prophylaxis
Stabilization
Prevention of complications
Monitoring neuro status
Family support and education
REHABILITATION
Do with the patient not for the patient
Management of impairment disability
or handicap
Patient family and others
Positioning
Exercise
Skin
Communication
Swallowing
Elimination

Cerebrovascular Accident

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