Cerebrovascular accident

1. CEREBROVASCULAR
ACCIDENT
Dr. JayeshPatidar
www.drjayeshpatidar.blogspot.com

2. 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
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3. 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
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4. 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)
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5. 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-98.6f
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6. 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
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7. PATIENT PRESENTATION -
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
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8. Assessment
BP-140/80 mmhg
HR-92b/mt
Spo2-99%
RR-20breaths/mt
Temp-98.6f
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9. 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
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10. Investigations
RBS-177 PPBS-141
Na-130
Cholesterol-239
Triglyceride-207
HDL-31/7.7
LDL-177
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11. 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
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12. PATIENT PRESENTATION -
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
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13. 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
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14. 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
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15. 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.
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16. CEREBRAL CIRCULATION
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17. 17
LOCATION
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18009.htm
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18. CLINICAL MANIFESTATIONS
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19. 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 impairedjudgement or insight into limitations,
overestimate physical ability, impulsivity, inappropriateness and difficulty
comprehending and expressing emotions
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20. COMMON EFFECTS OF A LEFT HEMISPERIC
STROKE
Right visual field loss (homonymous hemianopsia)
Dysphagia
May developaphasia (loss of language including spoken, written,
reading and comprehension)but may also havedysarthria
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
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21. 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
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22. 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
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23. 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
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24. 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
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25. 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
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26. EMERGENCY
MANAGEMENT
Neurological vital
signs
Blood pressure
Glycemic control
Control of body
temperature
Oxygenation
Hydration
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27. 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
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28. 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
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29. 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.
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30. 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.
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31. 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.
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32. 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 ABG’s
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33. Airway management adequate O2 saturation
Preventing increased ICP and providing supportive
care.
Hourly vitals/neuros including ICP, CPP, CVP.
Maintaining BP to ensure adequateCPP
Seizure precautions
Antibiotic prophylaxis
Stabilization
Prevention of complications
Monitoring neuro status
Family support and education
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34. REHABILITATION
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35. Do with the patient not for the patient
Management of impairment disability
or handicap
Patient family and others
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36. Positioning
Exercise
Skin
Communication
Swallowing
Elimination
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