cerebrovascular accident

cerebrovascular accident, commonly known as stroke is one of the most common health problems of the world. in the developing world, its increasing incidence is a matter of concern among the health workers across the globe. thus adequate knowledge about this medical condition is a must to deal with it effectively.

1. CEREBROVASCULAR ACCIDENT PRESENTED BY- GEETA JOSHI STATE COLLEGE OF NURSING

2. DEFINITION Cerebrovascular accident or Brain attack is sudden loss of function resulting from disruption of blood supply to a part of the brain.

3. ETIOLOGY MODIFIABLE RISK FACTORS- Hypertension Smoking & alcoholism Diabetes mellitus Cardiovascular disease Asymptomatic carotid stenosis Transient ischemic attacks Sickle cell anemia Dyslipidemia Obesity Poor diet ( increased fat & sodium, decreased Potassium) Physical inactivity Postmenopausal hormone therapy NON- MODIFIABLE RISK FACTORS Older age Gender (males) Heredity Prior stroke or heart attack

4. S. NO COMPARISION ISCHEMIC STROKE HEMORRHAGIC STROKE 1. CAUSE Large artery thrombosis small penetrating artery thrombosis Cardiogenic embolic cryptogenic others Intracerebral hemorrhage Subarachnoid hemorrhage Cerebral aneurysm Arteriovenous malformation 2. SYMPTOMS Numbness or weakness on one side of face especially arm & legs. Exploding headache . Decreased LOC 3. FUNCTIONAL RECOVERY Plateau at 6 months Plateau at 18 months

5. ISCHEMIC STROKE- TYPES Large artery thrombotic strokes- caused by atherosclerotic plaques in large arteries of brain , resulting in thrombus formation & occlusion. Small penetrating artery thrombotic strokes- also called Lacunar stroke, most common . Cardiogenic embolic stroke- due to cardiac dysrhythmias, usually atrial fibrillation.

6. Embolic strokes- caused by valvular heart disease & thrombi in left ventricle, can be prevented by use of anticoagulants. Cryptogenic strokes- no known cause. Others- illicit drug use, coagulopathy, migraine & spontaneous dissection of carotid or vertebral arteries.

7. PATHOPHYSIOLOGY- ischemic stroke Due to obstruction of a blood vessel Disruption in cerebral blood flow Cellular metabolic events Failure of neurons to maintain aerobic respiration Mitochondria switch to anaerobic respiration Production of lactic acid in large amounts Change in ph (ACIDOSIS) Inability of neuron to produce adequate energy Insufficient fuel for depolarisation Cessation of membrane pumps Accumulation of calcium & release of glutamate Activation of damaging pathways.

8. CLINICAL MANIFESTATIONS- ischemic stroke Numbness or weakness of face, arm or leg, especially on one side of body. Confusion Change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty in walking, dizziness or loss of balance Sudden severe headache

9. CLINICAL MANIFESTATIONS- ischemic stroke Hemiplegia, hemiparesis, flaccid paralysis Dysarthria, dysphasia, aphasia (expressive, receptive or global) Apraxia Hemianopsia Disturbed visual spatial relationships agnosia

10. CLINICAL MANIFESTATIONS SENSORY DEFICITS VERBAL DEFICITS MOTOR DEFICITS EMOTIONAL DEFICITS COGNITIVE DEFICITS VISUAL FIELD DEFECTS

11. DIAGNOSIS Careful history Complete physical & neurologic examination NCCT (non contrast computed tomography)- whether ischemic or hemorrhagic ECG Carotid ultrasound CT angiography MRI or MRA Transcranial Doppler flow studies Echocardiography SPECT

12. MEDICAL MANAGEMENT Platelet inhibiting medications- aspirin, clopidogrel Statins - 3- hydroxy 2-methyl glutaryl- coenzyme A , e.g. simvastatin Anti- hypertensive drugs- ACE inhibitors, thiazides Thrombolytic therapy- t-PA – Tissue plasminogen activator Anticoagulant therapy- INR above 1.7

13. DOSAGE- 0.9mg/kg with max. dose 90mg. 10% of the dose is administered IV bolus over 1 minute. Remaining 90%is administered over 1 hour. Obtain vital signs every 15 min for first 2 hours. t-PA THERAPY

14. Other treatments- Anticoagulant administration- heparin Osmotic diuretics- mannitol Elevation of the head Endotracheal intubation Neurologic assessment Hemodynamic monitoring

15. SURGICAL MANAGEMENT Endarterectomy - removal of atherosclerotic plaque from carotid artery. Carotid stenting with angioplasty. Carotid stenting without angioplasty.

16. NURSING MANAGEMENT Acute pain R/t Hemiplegia & disuse Impaired physical motility R/t loss of balance & coordination Self care deficit R/t stroke sequalae Disturbed sensory perception R/t altered sensory reception Impaired urinary elimination R/t flaccid bladder Disturbed thought process R/t brain damage

17. BEHAVIOURAL AND DIETARY MANAGEMENT PREVENTIVE MEASURES- Leading a healthy lifestyle. Quitting smoking. Maintaining a healthy weight. Daily exercise Following a healthy diet. DASH (dietary approaches to stop hypertension)- high in fruits & vegetables, low fat dairy products, low in animal proteins .