Cerebrovascular Disease

1. Cerebrovascular Disease
Ischemic Stroke
Hemorrhagic Stroke

2. ISCHEMIC STROKE
Also known as brain attack
is a abrupt loss of function resulting from
disrupted blood supply to a part of the brain.

3. Five Types according to causes:
 Large artery thrombosis – are due to atherosclerotic plaques in the large blood
vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis
result in ischemia and infarction.
 Small penetrating artery thrombosis – affects one or more vessels and are the most
common type of ischemic stroke.
- also known as Lacunar strokes because of the cavity that is created once the
infracted brain tissue disintegrates.
 Cardiogenic embolic strokes – are associated with cardiac dysrhythmias, usually
atrial fibrillation. Emboli originate from the heart and circulate to the cerebral
vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Emboli
stroke may be prevented by the use of anticoagulant therapy in patients with atrial
fibrillation.
 Cryptogenic stroke – iatrogenic.
 other strokes – from the use of cocaine, coagulopathies, migraine, and spontaneous
dissection of the carotid or vertebral arteries.

4. Stroke Continuum: Time Course
Classification
 Transient Ischemic Attack
- may serve as a warning of approaching strokes
- greatest incidence is in the first month following the first attack.
- temporary episodes of neurologic dysfunction manifested by a sudden loss of motor,
sensory, or visual function.
- last for a few seconds or minutes but no longer than 24 hours.
 Reversible Ischemic Neurologic Deficit
- sign and symptoms are consistent but more distinct than a TIA
- last for more than 24 hours
- symptoms revolve in days without permanent neurologic deficits.
 Stroke in Evolution
- worsening of neurologic sign and symptoms over several minutes or hours.
- Progressing stroke
 Complete Stroke
- stabilization of the neurologic signs and symptoms
- indicates no further progression of hypoxic insult to the brain from this particular
ischemic event.

5. Risk Factors
10. Drug abuse
9. Excessive alcohol consumption
8. Smoking
7. Use of Oral Contraceptive
6. Diabetes Mellitus
5. Elevated hematocrit
4. Genetics4. Obesity
3. Race3. High cholesterol levels
2. Sex2. Cardiovascular diseases
1. Age1. Hypertension
Uncontrollable Risk Factors Controllable Risk Factors

8. Pathophysiology
Occlusion of artery
Dec blood flow
Dec oxygenation and
nutrition of brain
Dec energy stores

9. Pathophysiology
Open Ca channels
Inc Ca, Na and Cl
Dec K
Inc cell death
Inc glutamine
and aspartate

10. Assessment
Motor Loss
Communication Loss
Perceptual Disturbances
Sensory Loss
Cognitive Impairment and Psychological
Effects
- Cognitive impairment
- Psychological problems

11. Cooperation of Left and Right
Hemispheric Stroke
Lack of awareness of deficits
Impulsive behavior and poor
judgment
Slow, cautions behavior
Increase distractibilityAltered intellectual ability
Spatial-perceptual deficitsAphasia (expressive, receptive, or
global)
Left visual field lossRight visual field deficit
Paralysis or weakness on left side
of the body
Paralysis or weakness on right side
of the body
Right Hemispheric Stroke Left Hemispheric Stroke

12. Diagnostic Examination
·Non Contrast Computed Tomography scan
12-lead electrocardiogram –standard test
Carotid ultrasound – standard test
Cerebral angiography
Transcranial Doppler flow studies
Transthoracic or transesophageal echocardiography
Magnetic resonance imaging
Xenon CT
Single photon emission CT
Carotid phonoangiography
Oculoplethysmography
·Carotid angiography
Digital subtraction angiography

13. Medical Management
Warfarin Sodium (Coumadin)
Platelet-inhibiting medication
Aspirin
- most cost effective
- 50 mg/d
Dipyridamole (Persantine)
- 400 mg/d
Clopidogrel (Plavix)
Ticlopidine (Ticlid)
Thrombolytic Therapy
Therapy for patients with ischemic stroke not receiving t-PA
Endarterectomy

14. Criteria for t-PA Administration
–18 years of age or older
–NIH stroke scale of 22
–Time of onset of stroke known and is 3 hours or less
–BP systolic < 185; diastolic of < 110
–Not a minor stroke or rapidly resolving stroke
–No seizure at onset of stroke
–Not taking warfarin
–Prothrombine time < 15 second or INR < 1.7
–Not receiving heparin during the past 48 hours with elevated partial
thromboplastin time
–Platelet count of > 100,000
–Blood glucose level between 50 and 400 mg/dL
–No acute myocardial infarction
–No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or
aneurysm
–No major surgical procedures within 14 days
–No stroke or serious head injury within 3 months
–No gastrointestinal or urinary bleeding within last 21 days
–Not lactating or postpartum within last 30 days.

15. Dosage and administration
of t-PA administration
–Weight the patient
–Minimum dose is 0.9 mg/kg; maximum of 90 mg.
–Load the 10% of the dose and is administered over 1
minute
–The remaining dose is administered over 1 hour via a
infusion pump
–After infusion is completed, flush the line with 20 ml of
normal saline solution.
–Monitor the vital signs every 15 minutes for the first 2 hours,
every 30 minutes for the next 6 hours, then every hours for
16 hours.

16. Side effects
Bleeding at the insertion site of IVF, urinary
catheter. ET tube, NGT, urine, stool, emesis,
and etc.
Intracranial bleeding

17. Therapy for patients with ischemic
stroke not receiving t-PA
Administer osmotic diuretics
Maintaining PCO2 within the range of 30-35
mmHg
Elevate the head of the bed
Intubation with an endotracheal tube, if
necessary
Continuous hemodynamic monitoring
Neurologic assessment

18. Endarterectomy
–used to manage TIAs
–most frequently performed peripheral vascular
procedure
–removal of an atherosclerotic plaque or thrombus
from the carotid artery to prevent stroke in
patients with occlusive disease of the extracranial
cerebral artery.

19. Post operative Nursing management
for Endarterectomy
Maintain adequate blood pressure
Close cardiac monitoring
Assess neurologic status
Assess the cranial nerves VI, X, XI, and XII.
Observe fro swelling and hematoma
formation.

20. Managing potential complication
Maintain cardiac output
Administer oxygenation

21. Potential Complication
–Decrease cerebral blood flow due to increase
ICP
–Inadequate oxygen delivery to the brain
–Pneumonia

22. NURSING PROCESS: The Patient
Recovering from an Ischemic Stroke

23. Assessment
Change in the level of consciousness or responsiveness as
evidenced by movement, resistance to change of position and
response to stimulation; orientation to time, place, and person.
Presence or absence of voluntary and involuntary movements of
the extremities; muscle tone; body posture; and position of the
head.
Stiffness or flaccidity of the neck
Eye opening, comparative size of pupil and papillary reactions to
light and ocular position
Color of the face and extremities; temperature and moisture of the
skin
Quality and rates of pulse and respiration; arterial blood gas values
as indicated, body temperature, and arterial pressure
Ability to speak
Input and output q 24 hours
Presence of bleeding
Maintain blood pressure within the desire parameters.

24. Nursing Diagnosis
Impaired physical mobility related to hemiparesis,
loss of balance and coordination, spasticity, and
brain injury
Acute pain (painful shoulder) related to hemiplegia
and disuse
Self-care deficits (hygiene, toileting, grooming, and
feeding) related to stroke sequelae
Disturbed sensory perception related to altered
sensory reception, transmission, and/or integration.
Impaired swallowing
Incontinence related to flaccid bladder, detrusor
instability, confusion, or difficulty in communicating

25. Nursing Diagnosis
Disturbed thought processes related to brain
damages, confusion, or inability to follow instructions
Impaired verbal communication related to brain
damages
Risk for impaired skin integrity related to
hemiparesis/hemiplegia, or decreased mobility
Interrupted family processes related to catastrophic
illness and care giving burdens
Sexual dysfunction related to neurologic deficits or
fear of failure

26. Planning and Goals
For the patient to improve mobility
Avoidance of shoulder pain
Achievement of self-care
Relief of sensory and visual deprivation
Prevention of aspiration
Continence of bowel and bladder
Improvement of thought process
Achieving a form of communication
Maintain skin integrity
Restore family functioning
Improvement in sexual functions
Absence of complication

27. Nursing Interventions
1.Improving mobility and preventing joint deformities
a. Preventing shoulder adduction
Assist in maintaining body alignment and prevent
compressive neuropathies
Applying a posterior splint during sleep at night to
the affected extremity.
Place a pillow in the axilla when there is a limited
external rotation of the shoulder.

28. b. Positioning the hand and fingers
The hand is placed in slight supination. (palms facing
upward)
If upper extremity is flaccid, use a volar resting splint If the
extremity is spastic, use a dorsal wrist splint, instead of hand
roll
c. Changing position
Change position q2 hours.
Place the patient in a lateral position, a pillow is placed
between the legs before the patient is turned.
If possible, the patient is placed in a prone position for 15 to
30 minutes several times a day.
Nursing Interventions

29. d. Establishing an exercise program
Passive exercise and put through a full range in motion
4 or 5 times a day .
Quadriceps muscle setting and gluteal setting exercises
are started early in
e. Preparing for ambulation
Use a tilt table, which slowly brings the patients.
Chair should be low enough
Use of parallel bars. A chair or wheelchair should be
available if the patent suddenly becomes fatigue.
A three or four pronged cane
Nursing Interventions

30. f. Preventing shoulder pain
The nurse should never lift the patient by flaccid
shoulder or pull on the affected arm or shoulder.
The flaccid arm is positioned on a table or with
pillows while the patient is seated.
The patient is instructed to interlace the finger, place
the palms together, and push the clasped hands
slowly forward to bring the scapulae forward.
Pushing the heel of the hand firmly down on a
surface is useful
Amitriptyline hydrochloride (Elavil)
Nursing Interventions

31. 2. Enhancing self-care
As soon as the patient can sit up, personal hygiene
activities are encourage.
Use of assistive devices
The family are instructed to bring clothing that are
size larger than that normally worn
Clothing fitted with front or fide fasteners or Velcro
Closure is most suitable.
The patient is dressed better in a seated position.
Keep the environment organized and uncluttered.
The clothing are placed on the affected side in the
order in which the garments are to be put on.
Use a large mirror while dressing
Nursing Interventions

32. 3. Managing sensory-perceptual difficulties
Approached on the side where visual perception is intact
All visual stimuli should be placed on this side. E.g. clock,
calendar and television)
The patient can be taught to turn the head in the direction
of the defective visual field
The nurse should make eye contact with the patient and
draw his or her attention to the affected side
Stand at a position that encourage the patient
Increase the natural or artificial lighting in the room and
provide eyeglasses.
Constantly remind the patient about the other side of the
body.
Place the extremities where the patient can see them.
Nursing Interventions

33. 4. Managing dysphagia
Advice to take smaller boluses of food, and taught
about which foods are easier to swallow
The patient is initially started on a thick liquid or
purred diet.
Having the patient sit upright position
Instruct to him or her to tuck the chin toward the
chest as he or she swallow to prevent aspiration.
Nursing Interventions

34. 5. Managing Tube feeding
Elevate the head of the bed at least 30 degrees
Check the position of the tube before feeding,
ensuring the cuff of the tracheotomy tube is inflated.
Give the tube feeding slowly
Aspirate periodically to ensure that the feeding are
passing through the gastrointestinal tract.
Nursing Interventions

35. 6. Attaining bowel and bladder control
Intermittent catheterization
Upright posture and standing position are helpful for
male patients during this aspect of rehabilitations
Nursing Interventions

36. 7. Improving thought processes
Review the neuropsychological testing
Observes the patient’s performance and progress,
gives feedback
Nursing Interventions

37. 8. Improving communication
A consistent schedule, routines, and repetitions help
the patient to function despite significant deficits.
A written copy of daily schedule, a folder of personal
information, checklists, and an audiotape list help
improve the patient’s memory and concentration.
The patient’s attention, speak slowly and keep the
language of instruction consistent.
One instruction at a time and time to allow the
patient to process what has been said.
Nursing Interventions

38. 9. Maintaining Skin integrity
Frequent assessment of the skin with the emphasis
on the bony areas.
Use specialty bed
Regular timing and positioning schedule
Nursing Interventions

39. 10. Improving family coping
They are given information about the expected outcomes
Counseled the family to avoid doing for the patient those
things that he or she can do.
Inform the family that the rehabilitation of the hemiplegic
patient requires progress may be slow.
The family can help by approaching the patient with
supportive and optimistic attitude, focusing on the abilities
that remains,
The family should be prepared to expect occasional
episodes of emotional lability.
Explain to the family that patient’s laughter does not
necessarily mean happiness, as well as crying does not
reflect sadness.
Nursing Interventions

40. 11. Helping the patient cope with sexual dysfunction
·Providing information, education, reassurance, how
to adjust to the medication, providing counseling
regarding coping skills and suggesting about
alternative positions to the patient and the partner
about
Nursing Interventions

41. Evaluation:
The patient expected outcome may include:
1. Achieve improved mobility
Avoids deformities (contractures and footdrop)
Participates in prescribed exercise program
Achieves sitting balance
Uses unaffected side to compensate for loss of function of
hemiplegics side
2. Report the absence of shoulder pain
Demonstrates shoulder mobility; exercises shoulder
Elevates the arms and hands at intervals
3. Achieves self-care; performs hygiene care: uses adaptive
equipment
4. Turn head to see people or objects
5. demonstrates improved swallowing ability
6. Achieves normal bowel and bladder elimination

42. 7. Participates in cognitive improvement program
8. demonstrates improved communication
9. Maintains intact skin without breakdown
Demonstrates normal skin turgor
Participates in turning and positioning activities
10. Family members demonstrate a positive attitude and coping
mechanism
Encourage patients in exercise programs
Take an active part in rehabilitation process
Contact respite care programs or arrange for other family
members to assume some responsibilities for care
11. Has positive attitude regarding alternative approaches to
sexual expression
Evaluation:

43. HEMORRHAGIC STROKE
are caused of bleeding in the brain tissue,
the ventricles, or the subarachnoid space.

44. Types of Hemorrhagic Stroke
Primary intracerebral hemorrhage
–is from spontaneous rupture of small vessels
accounts for approximately 80%
–caused by uncontrolled hypertension
Secondary intracerebral hemorrhage
–associated with arteriovenous malformations,
intracranial aneurysms or certain medications.

45. Intracerebral Hemorrhage
most common in patients with hypertension and
cerebral atherosclerosis because degenerative
changes from these diseases caused by rupture
vessel.
 also due to certain types of arterial pathology, brain
tumor, and the use of medication.
bleeding usually is arterial in origin and most
commonly in the cerebral lobes, basal ganglia,
thalamus, brain stem and cerebrum.
 most fatal if the bleeding cause intraventricular
hemorrhage

46. Intracranial (Cerebral) Aneurysms
dilatation of the walls of the cerebral artery
that develops as a result of weakness in the
arterial wall.

47. Most commonly affected by an
aneurysm:
Internal carotid artery
Anterior cerebral artery
Anterior communicating artery
Posterior communicating artery
Posterior cerebral artery
Middle cerebral artery

48. Arteriovenous Malformations
abnormality in embryonal development that leads to
a tangle of arteries and veins in the brain without a
capillary bed.
most common in young people.

49. Subarachnoid Hemorrhage
may occur as a result of arteriovenous malformations

50. Pathophysiology

51. Pathophysiology
Hypertension
Inc pressure to the
vessels
Rupture of the blood
vessels
Bleeding

52. Pathophysiology
Compression of the
adjacent to the brain
tissue
Neuronal
dysfunction

53. Clinical Manifestation:
sudden severe headache
often loss of consciousness
nuchal rigidity
visual disturbances such as diplopia, ptosis, visual
loss
tinnitus
dizziness
hemiparesis

54. Diagnostic Findings:
Computed Tomography
Cerebral angiography – confirms the diagnosis
Lumbar puncture
Toxicology screening
Use of Hunt-Hess Classification of systems

55. Hunt-Hess Classification of systems
Modified classification adds the following
No acute meningeal/brain reaction, but with fixed neurological
deficit
Ia
Unrupture aneurysm0
Deep coma, decerebrate rigidity, moribund appearance
Add one grade for serious systemic disease or severe vasospasm
on angiography
V
Stupor, moderate to severe hemiparesis, early decerebrate rigidityIV
Mild focal deficit, lethargy, or confusionIII
Cranial nerve palsy, abducens, moderate-to-severe headache,
nuchal rigidity
II
Asymptomatic, or mild headache and slight nuchal rigidity I

56. Medical Management:
1. Cerebral Hypoxia and Decrease Blood Flow
a. administering oxygen
b. maintaining the hemoglobin and hematocrit level
c. adequate hydration through IV fluids
d. avoid extreme hypertension or hypotension
e. treat seizures
2. Vasospasm
a. surgery to clip aneurysm
b. Calcium-Channel blocker through IV administration
- nimopidipine
- verapamil
- nifedipine
c. Endovascular technique

57. Medical Management:
3. Increase ICP
a. lumbar punctured
b. ventricular catheter drainage
c. diuretics (mannitol)
4. Systemic Hypertension
a. antihypertensive therapy
- labetalol (Normodyne)
- nicardipine (Cardene)
- nitroprusside (Nitropress)
b. Hemodynamic monitoring
c. Anti-seizure agents
c. Stool softener
5. Surgical Management
a. extracranial-intracranial arterial bypass

58. Post-operative complication
–Disorientation
–Amnesia
–Korsokoff’s syndrome
–Personality changes
–GI bleeding
–Intraoperative embolization
–Postoperative internal artery occlusion
–Fluid and electrolyte disturbances

59. NURSING PROCESS: The patient with
a Hemorrhagic Stroke

60. Assessment
altered level of consciousness – early sign
sluggish pupillary reaction
motor and sensory dysfunction
cranial nerve deficits
speech difficulties and visual disturbances
headache and nuchal rigidity

61. Nursing Diagnosis
Ineffective cerebral tissue perfusion related to
bleeding
Disturbed sensory perception related to medically
imposed restrictions
Anxiety related to illness and/or medically imposed
restrictions

62. Planning and Goals
Improve cerebral tissue perfusion
Relief of sensory and perceptual deviation
Relief of anxiety
Absence of complication

63. Nursing Intervention:
1. Optimizing Cerebral Tissue Perfusion
–Monitor neurologic deterioration
–Check hourly the blood pressure, pulse, LOC, papillary
responses and motor function. And any changes should
be reported immediately
2. Implementing Aneurysm Precaution
–Provide a nonstimulating environment
–Prevent further increase in ICP pressure
–Bed rest
–Provide quiet, nonstressful environment
–Visitor are restricted (except for the family)
–Elevate head in 15-30 degrees
–Avoid sudden increase in blood pressure

64. Nursing Intervention:
–Avoid vasalva maneuver, straining, forceful sneezing,
pushing up in bed, acute flexion or rotation of the head and
neck and cigarette smoking
–Instruct the patient to exhale through the mouth during
voiding or defecation
–No enema are permitted
–Dim lighting
–Coffee and tea, unless contraindicated
–Thigh-high elastic compression stockings or sequential
compression boots
–The nurse administers all personal care
–External stimuli are keep in minimum.
3. Relieving Sensory Deprivation and Anxiety
–Keeping the patient well informed of the plan of care
–Provide information and support to the family

65. Potential Complication:
Vasospasm
Seizure
Hydrocephalus
Rebleeding

66. Managing Potential Complications:
Vasospasm
–Calcium-channel blocker
–Fluid volume expanders
Seizure
–Maintaining the airway
–Prevent injury
–Drug of choice: phenytoin (Dilantin)
Hydrocephalus
–Ventriculoperitoneal shunt
–Any change in patients responsiveness are reported immediately
Rebleeding
–Monitor for initial signs of hemorrhage usually after 2 weeks of
after hemorrhage
–Administer anti-fibrinolytic agents (epsilon-aminocaproic acid) as
prescribed to delay the lysis of the clot surrounding the rupture

67. Evaluation:
The patient is expected outcome:
Demonstrates intact neurologic status and normal vital signs
and respiratory patterns
–Is alert and oriented to time, place and person
–Demonstrates normal speech patterns and intact cognitive
processes
–Demonstrate normal and equal strength, movement, and
sensation of all four extremities
–Exhibits normal deep tendon reflexes and papillary responses
Demonstrates normal sensory perceptions
–States rationale for aneurysm precaution
Exhibits clear thought process

68. Exhibits reduced anxiety level
–Is less restless
–Exhibits absence of physiologic indicators of anxiety
Is free of complication
–Exhibits absence of vasospasm
–Exhibits normal vital signs and neuromuscular activity
without seizures
–Verbalizes understanding of seizure precautions
–Exhibits normal mental status and normal motor and
sensory status
Report no visual changes
Evaluation: